MJ Taylor's Dissertation by Matthew J Taylor Institute

RE-MEMBERING OUR BACK PAIN: DISCOVERING THE GAPS IN OUR SELF-CARE THROUGH A PARTICIPATORY BACK SCHOOL

Matthew J. Taylor

A Dissertation Submitted to the Faculty of the California Institute of Integral Studies in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY with a concentration in Transformative Learning and Change

California Institute of Integral Studies

San Francisco, CA

2005

CERTIFICATE OF APPROVAL

I certify that I have read RE-MEMBERING OUR BACK PAIN: DISCOVERING THE GAPS IN OUR SELF-CARE THROUGH A PARTICIPATORY BACK SCHOOL by Matthew J. Taylor, and that in my opinion this work meets the criteria for approving a dissertation submitted in partial fulfillment of the requirements for the Doctor of Philosophy degree in Transformative Learning and Change at the California Institute of Integral Studies.

_________________________________________________ Alfonso Montuori, Ph.D., Chair Professor, Transformative Learning and Change

_________________________________________________ Rachel Martin, Ph.D. Professor, Transformative Learning and Change

_________________________________________________ Staffan Elgelid, P.T., Ph.D., Department of Physical Therapy Associate Professor, Nazareth College, Rochester, NY

_________________________________________________ W. Roy Whitten, Ph.D., Peer Review Member California Institute of Integral Studies

ÂŠ 2005 Matthew J. Taylor

Matthew J. Taylor California Institute of Integral Studies, 2005 Alfonso Montuori, Ph.D., Committee Chair

ABSTRACT

For individuals with a diagnosis of chronic back painâ&#x20AC;&#x201D;CBPâ&#x20AC;&#x201D; who have exhausted other resources, a final treatment option traditionally has been attending a back school to learn a mechanistic approach to managing and living with CBP. The success of back schools over 30 years has been mixed at best, despite numerous designs and curricula. This study attempted to change the delivery model of back schools to a new pedagogy and to broaden the perspectives addressed in the curriculum to better accommodate the complexity of CBP and identify the individual needs of the person living with CBP. The format for this qualitative study was collaborative inquiry, a form of participatory action research. The study was a case study of a group of eight participants, including the researcher, who participated in an eight-week prototype, participatory back school (PBS). The study spanned 14 weeks from entry interview to final post-treatment survey. The data focused on the experiences of the individuals and the group as a whole. The results indicated a multiple systems effect that promoted limited selfcare and suggested that in light of new understandings about chronic pain, the traditional back school model may require significant restructuring. In addition to self-care skills, valuable skills were identified for future participants and v

facilitators who might participate in a PBS. The participants reported value in the interactive group learning process and the materials on the emotional and spiritual influences on chronic pain. Each participant struggled with compliance, despite having experienced the support and insight the new skills provided and having the resources to continue the new behaviors. Participant reflections on this failure to comply suggested a spiritual dilemma rather than a motivation or learning deficit.

ACKNOWLEDGEMENTS

Of the many people that made this project possible and deserve to be acknowledged, I wish to express my gratitude to: Ellen Friedman, my guardian angel and provider of patients, participants, and so much generosity; Sal and Diana, neighbors extraordinaire, for sharing your special home in the mountains that allowed this project to come to life; Pam Bosch and the A. T. Still University of Health Sciences for the privilege of teaching your students and your generosity in sharing your library resources; Roy Whitten for blazing the trail, being there every step of the way, and helping me stay awake and aware; Charlie Trull, my brother and friend, you make my heart dance and stood by as this project was born in the mountains of Pine; Nick, Valerie, Rob, Doug, Eric, Anne, and Rob for daring to be part of something new and putting your pain, your heart, and your spine into this study to truly give it flesh; The gang at Dynamic Systems Rehabilitation, PLLC for daring to dream of a more compassionate and comprehensive way of caring for others and ourselves, and patiently tolerating my dissertation maternity leave;

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Monty Montuori, advisor and educator, for fanning the flames of passion for knowledge and the creativity that sparked the idea for this project and saw it through to completion; Rachel Martin for showing up as a last minute assistant in my dissertation proposal class and teaching me how to breathe life into research through qualitative inquiry; Staffan Elgelid and Jerry Gillon, co-conspirators and partners in all matters of sparking change within our beloved profession, for teaching me to write plainly and when appropriate, dispassionately; Mary and Jerry Taylor, my parents, for teaching me the value of hard work, sacrifice, and keeping complaining to a minimum; Emily, Adam, and Anthony, my children, for patiently watching their father work long hours to create a better world for them and their children, and giving me a purpose in my work; Jennifer, for growing with me through this entire project and being the one who said â&#x20AC;&#x153;Yesâ&#x20AC;? so many times when it meant postponing or missing other opportunities . . . here we go off into another chapter together!

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TABLE OF CONTENTS ABSTRACT ............................................................................................................ v ACKNOWLEDGEMENTS .................................................................................. vii LIST OF TABLES ............................................................................................... xiii CHAPTER I: INTRODUCTION............................................................................ 1 Researcher’s Context ........................................................................................... 1 Definitions ........................................................................................................... 4 The Research Question ........................................................................................ 6 Purpose of This Study.......................................................................................... 8 Significance of the Research ............................................................................... 8 Researcher’s Assumptions................................................................................... 9 CHAPTER II: LITERATURE REVIEW ............................................................. 13 Background........................................................................................................ 14 Individual Approaches ............................................................................................... 17 Group Approaches ..................................................................................................... 17

The History and Models of Back Schools .................................................. 19 Similarities among Back Schools ............................................................... 22 Differences among Back Schools ............................................................... 23 Outcomes .................................................................................................... 25 Back schools compared to other treatments for CBP. ............................ 27 Back schools compared to waiting list controls and placebo. ................ 27 Back schools in occupational settings compared to other treatments. ... 28 Back schools in occupational settings compared to waiting list controls and placebo. ......................................................................... 29 Other groups. .......................................................................................... 30 The Assumptions Underlying Back Schools in Group Approaches .......................... 31

The Review ........................................................................................................ 32 The History and Development of the “Parts” View .................................................. 33 How the “Parts” View Has Limited Understanding of CBP ..................................... 34 Evidence Underlining the Need to Address the Complexity of CBP ........................ 36

Examples in the Clinic ................................................................................ 37 Individual approach to treatment............................................................ 37 Behavioral interventions. ....................................................................... 38 Lost in the system. .................................................................................. 40 Focus on the “bad part.” ......................................................................... 40 Examples in Research ................................................................................. 42 Evidence-based medicine. ...................................................................... 43 The search for additional randomized controlled trials. ......................... 44 Examples of Patient/Consumer Expectations ............................................. 46 The complexities of chronic back pain. ................................................. 47 Race and Diversity Challenges ................................................................... 50 ix

Anticipating the Future .............................................................................................. 52

Lille Study................................................................................................... 53 Tailored Treatment...................................................................................... 55 Summary............................................................................................................ 59 CHAPTER III: METHODOLOGY ...................................................................... 61 Situating the Question in a Research Paradigm: ............................................... 61 A Qualitative Approach ..................................................................................... 61 Critical Theory ........................................................................................................... 62 Constructivism ........................................................................................................... 62 The Participatory Paradigm ....................................................................................... 63

Characteristics of Qualitative Inquiry................................................................ 65 Participatory Action Research (PAR)................................................................ 69 Key Characteristics of Participatory Action Research .............................................. 70

Four Ways of Knowing ............................................................................... 70 Cycles of Reflection and Action ................................................................. 72 Selecting a Method: ........................................................................................... 74 Case Study ......................................................................................................... 74 Limitations of Case Studies ....................................................................................... 75 Steps Involved in a Case Study ................................................................................. 76

Collaborative Inquiry in the Participatory Back School .................................... 77 Skills Required to Conduct Collaborative Inquiry .................................................... 79

Selection of Participants .................................................................................... 80 The Data ............................................................................................................ 82 Sources of Data .......................................................................................................... 82 Data Collection Procedures ....................................................................................... 83 Encountering and Analyzing the Data ....................................................................... 86

Specific Analysis Procedures ...................................................................... 86 Analyzing the Data ..................................................................................... 87 Validity and Reliability ..................................................................................... 88 Internal Validity ......................................................................................................... 88 External Validity........................................................................................................ 90 Reliability .................................................................................................................. 92

Limitations and Delimitations ........................................................................... 94 Limitations ................................................................................................................. 94 Delimitations ............................................................................................................. 95

CHAPTER IV: RESULTS .................................................................................... 97 Overview of Our PBS Experiences ................................................................... 97 Recruitment and Intake Interviews ............................................................................ 97 Week 1 ....................................................................................................................... 98 Week 2 ....................................................................................................................... 99 Week 3 ..................................................................................................................... 100 Week 4 ..................................................................................................................... 101 Week 5 ..................................................................................................................... 101 Week 6 ..................................................................................................................... 102 Week 7 ..................................................................................................................... 102 Week 8 ..................................................................................................................... 103 Exit Interviews and Final Questionnaires ................................................................ 104 x

The Participants ............................................................................................... 104 Nick ......................................................................................................................... 105 Frank ........................................................................................................................ 107 Anne......................................................................................................................... 109 Rob .......................................................................................................................... 110 Valerie ..................................................................................................................... 112 Eric........................................................................................................................... 114 Doug ........................................................................................................................ 116 Matt.......................................................................................................................... 117 The Group ................................................................................................................ 120

Discoveries from Our Experiences .................................................................. 122 Benefits and Skills Acquired during PBS ................................................................ 123 Improvements Reflected in Scales Summary .......................................................... 125 Changes in Personal Narratives ............................................................................... 128 Changes in Future Consumer Behaviors ................................................................. 131 Group Process Experience ....................................................................................... 132 Required Participant Skills Identified during the PBS ............................................ 134

Skills Participants Need ............................................................................ 134 Skills Facilitator Needs ............................................................................. 135 Practical Participant Tools and Business Considerations ........................................ 136 Marketing................................................................................................................. 136 Consumer Biases ..................................................................................................... 138 The Value of Receiving Individual Instruction/Experience .................................... 139 Educational Tools and Materials for Home Action and Reflection ......................... 140 Online Educational Experience ............................................................................... 142 The Influence of Other Systems on Compliance and Participation ......................... 143

Chapter V: DISCUSSION ................................................................................. 146 Towards a Transdisciplinary Approach ........................................................... 147 The Challenge of Crossing the Boundaries ............................................................. 148

Changes in Perspective .................................................................................... 150 Expectations of Knowledge â&#x20AC;&#x153;Acquisitionâ&#x20AC;?...................................................... 151 Source of Knowledge for Self-Care ................................................................ 152 Responsibility for/Source of the Pain .............................................................. 153 Paradigmatic Approaches ................................................................................ 154 Skill Sets for Providers .................................................................................... 156 Intention and Emphasis of Inquiry .................................................................. 158 Suggestions for Further Research .................................................................... 160 Proposed Improvements for Follow up on this Study ............................................. 160 Improving Compliance in a PBS ............................................................................. 161

Definitions and Background ..................................................................... 161 Reasons for Noncompliance ..................................................................... 163 Suggestions to Enhance Compliance ........................................................ 164 Past Discussions of How to Address Motivation and Compliance........... 167 Areas of Inquiry to Broaden the View and See the Whole ...................................... 170 Suggested Research Questions for Consideration ................................................... 174

Reflections on 2 Self-care vs. Self-neglect: A Larger Systems Issue ............ 175 Summary and Conclusion ................................................................................ 176 xi

REFERENCES ................................................................................................... 179 APPENDICES .................................................................................................... 191 Appendix A: Intake Interview Questionnaire .................................................. 191 Appendix B: Dissertation Study Exit Interview ............................................. 195 Appendix C: Participant’s Journal Weeks 1-7 ................................................ 197 Appendix D: Participant’s Journal Week 8 .................................................... 198 Appendix E: Participant’s Journal—The Science of Personal Systems Inquiry (SPSI) ............................................................................................. 199 Appendix F: Consent Form ............................................................................. 206 Appendix G: Opening Night Checklist ........................................................... 208 Appendix H: Completed Narrative .................................................................. 210 Appendix I: Week 2......................................................................................... 212 Appendix J: Week 3 ....................................................................................... 215 Appendix K: Week 4 ...................................................................................... 217 Appendix L: Week 5....................................................................................... 220 Appendix M: Week 6 ..................................................................................... 221 Appendix N: Week 7 ...................................................................................... 225

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LIST OF TABLES Table 1 Evolutionary Mechanisms in Chronic Low Back Pain ..................................................... 49 Table 2 Phases and Components for Individually Tailored Intervention ...................................... 57 Table 3 Changes in Pain and Disability Experienced + 30 Days after a PBS ............................ 127 Table 4 New Perspectives for Chronic Back Pain Inquiries........................................................ 151

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CHAPTER I: INTRODUCTION

Researcher’s Context Nineteen years ago I joined the ranks of my patients in my physical therapy practice, experiencing my first episode of back pain. Suddenly I had both empathy and a renewed motivation to find “the answer.” How did I find myself in such a predicament? As a highly trained, aggressive orthopedic physical therapist, I knew all of the physical “parts” and how to move those parts, yet my condition continued to deteriorate. The first 15 years of my career focused on a biomechanical understanding of back pain. I searched for the prescriptive exercises—such as how long, how much pressure, or how many repetitions—that would be the right answer for my patients’ conditions. If no part could be identified, or the part had been literally removed, I examined other components, including mental health, socioeconomic variables, and mechanical demands on the spine (Waddell, 1991). I realize now that my approach proceeded from the mechanistic worldview held in my profession and in Western medicine generally. Our focus was on finding and fixing the offending part. We looked for the single right thing to “do” to patients or have them do to effect a cure. We did not take into account alternative approaches that might address additional factors such as emotions or spiritual concerns. The major transformative moment came in 1996 when I skeptically participated in a new weekly yoga class at my health club over a two-month 1

period. One day I just suddenly knew something was different . . . this yoga was “working” in a way that all the exercises, manipulations, supports and treatments never had. My entire model of healing was turned on its head, both figuratively and literally. At first I searched for the component or part of yoga that was working, but soon realized there was something more profound underway that defied attempts to isolate any part from the whole. Not only had my back pain diminished, but I also was happier, less frightened, and more tolerant of everyday annoyances. The healing process was touching all avenues of my life. Fourteen months after starting yoga, I made understanding this experience my life’s work. I enrolled in two yoga therapy training programs during which I experienced a profound “spiritual-somatic” event. In the first training, during a particular sustained and supported physical yoga posture, I discovered an insight that I identify as spiritual. From somewhere deep within I heard, “You don’t need to run anymore.” Run in that context meant for me that I could let go of trying to control and anticipate every circumstance . . . I could metaphorically walk or just wait patiently without having to clutch at every moment out of control or fear. This was a state of consciousness I had never previously known, and it left me with a personal commitment that emboldened me to take new risks in life out of a deep sense of trust. How could the yogic stretching of my hamstrings mechanically manifest such an event? How was it possible to hear what would be such a clear, life-directing insight during a physical intervention for back pain?

I returned home from the training and completely redirected my life and my career. I gave up my full patient care schedule and formed a corporation to begin teaching others about my discovery. My preparation for those presentations, later followed by my formal studies over the past four years, has unraveled the fabric of the lived experience of CBP. I have discovered many influences that call for a deeper, more integral approach to health care in today’s complex society. The existing mechanistic and unidirectional care model does not address these influences. What other, perhaps nonphysical, factors might be contributing to the complexity of supporting individuals with CBP? What was behind my own back pain experience that led to the changes I experienced in my transformation? This researcher, who formerly hesitated to even ask a question at a seminar, now travels the country teaching others, proposing a new model of care to the entire community of professionals dedicated to helping others with back pain. Could it be that chronic pain might offer a possibility for deep, transformative learning and change in others’ lives, too? My passion is to explore the integral experience of coming together with others to find healing and community. The understanding I have acquired through my personal experiences and doctoral studies speaks to the power of community to support and inform the individual in sickness and in health. I was constantly “on the run” in an attempt to control my environment. My disillusionment with my church of family origin, my local community of peers, material and financial success, and general lack of joy were the result of my fragmented human experience. A long process of progressively deeper levels of inquiry and

introspection, in conjunction with related practical action, were vital to my genuine healing. I now realize that I did not experience this process as an isolated individual, but as a member of multiple communities that included my fellow yoga students, my family, my professional colleagues, and most recently my doctoral learning community. I believe there is untapped creative healing potential in a group/community process of care, education, and support for those with CBP. That group process has the potential to lead to deeper personal insights, new practical pain management techniques, and the generation of alternative healing scenarios. Additionally, the deep, personal, and communal experience of group process might help individuals address essential questions—who am I and what am I? For me, it also helped define the ways in which I want to assist those with chronic spine pain. My own experience of chronic spine pain suggests the need to investigate the problem of CBP through a flexible, inclusive group process— nested within the many systems of modern society that influence CBP.

Definitions The following definitions will be utilized in this study: •

Participatory Action Research (PAR): A form of qualitative research involving a more democratic process of inquiry and practical action than quantitative methods. PAR is described in detail within the context of qualitative research (Reason & Bradbury, 2001) in Chapter III.

•

Collaborative Inquiry: A form of PAR that is the model of inquiry upon which my participatory back school is derived. The model is flexible, unique to the participants, and gives participants control over curriculum and activities (Heron & Reason, 1997). Collaborative inquiry is described in detail in Chapter III.

•

Participatory Back School (PBS): An educational process of inquiry created by the researcher that is based on the collaborative inquiry research method. Participants (also called co-researchers) are expected to participate in setting the curriculum based on their specific needs and to take an active role in acquiring and sharing skills and knowledge that are of interest or have been beneficial in their experience with CBP. The caregiver/facilitator participates as a content expert, methodological expert, and as a participant/co-researcher.

•

Learning Community: The interaction of the participants practicing and sharing resources and experiences creates a community experience not mentioned in the traditional back school literature (Heron & Reason, 1997).

•

Skills and Awareness: The personal and interpersonal skills and forms of consciousness that are required in a participatory learning community (Heron & Reason, 1997). The traditional, more passive back school model, makes few demands on the participant and can be completed with little or no self-awareness or engagement of

social/emotional/spiritual inquiry. These skills and awarenesses will be further discussed in Chapter III. •

Integral: A holistic perspective that understands the human experience to be more complex than a reductionistic approach can explain (Davis, 2000). An integral view suggests that care should not be limited to the person’s anatomical systems, but should include the many other systems of culture and environment that influence their spine pain.

•

Spiritual: Spirituality has been defined by Koenig, McCullough, and Larson (2001) as: the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community. (p. 24) For the purposes of this study I will narrow my operational definition to: the aspects of the human experience that ask and inform the individual’s unique experience of answering the questions: Who am I, What am I, and How shall I act or be in the world?

The Research Question My core question for this study was: What is the experience of people with CBP who participate in a back school program that is based on a collaborative inquiry model? Beyond this core question, there were also subquestions (Creswell, 2003). These subquestions directed the questions that I asked in gathering the data, informed the ways in which I modified the exit interviews, and ultimately helped

to shape the structure and format of this dissertation. Going into the study I knew that I wanted to ask these questions: 1. What skills or types of awareness do participants and facilitators have to possess to effectively participate in a PBS? 2. What practical skills do participants gain in dealing with the complexities of back pain in a modern society during a participatory back school? 3. How can a local group of individuals come together as a learning community to support and teach one another practical knowing and understanding relevant to individual context? 4. What would be a pragmatic way in which issues of spirit (who am I, what am I, and how should I be/act?) might be addressed within a broadly acceptable rehabilitation model? There were research issues that became apparent as the study progressed which led us to ask these additional questions: 5. What new topics would be included in the curriculum the participants developed that have not been reported or emphasized in the literature? 6. What practical instructional tools and guidelines are needed for the participant for home cycles to act and reflect at home? 7. What factors made compliance and participation difficult for the participants and the facilitator? 8. What was the value of receiving individual personal instruction in addition to the group presentation?

9. What was the impact of this program on the quality of life and functional abilities of the participants?

Purpose of This Study The purpose of this study was to examine and describe in rich detail a prototype participatory back school model for the support of those who are living with CBP. This study introduced a new pedagogy of back school education that addressed the complexity, individuality, and depth of influence CBP has on the individual. The participatory nature of the model also provided an opportunity to observe what new curriculum topics the participants would choose to develop that have not been reported or emphasized in the literature.

Significance of the Research This study offers a new model for both providers and individuals living with CBP to discover both meaning and self-care possibilities in their experience. The active PBS model shifts responsibility to the empowered consumer and could provide a cost-efficient model of back school delivery that can simultaneously address the needs of individuals and diverse populations. The study provided an opportunity to utilize the healing benefits of group interaction. Through active participation, the co-researchers identified and acquired practical new skills. Additionally, the school created a format that informed the professional development of the facilitator/healthcare provider while relieving the unrealistic expectations of being the expert for all of the participantsâ&#x20AC;&#x2122; needs.

The facilitator’s reflections identified skills required for the academic and clinical preparation of healthcare students that would be applicable to this participatory method. This participatory model may serve as a template for a broad category of diagnoses—including hypertension, diabetes, fibromyalgia, arthritis, and irritable bowel syndrome—that are amenable to this process (Reason & Bradbury, 2001). These varied diagnoses are not all supported by physical medicine rehabilitation practitioners; however, the scope of practice and the participatory nature of this model could lend itself to increased programming opportunities. The publication of this study and its methodology in traditional literature will serve as an introduction to an entirely different way of supporting people with CBP. The study opens two new fields of inquiry: 1) the PBS model, and 2) practical tools for physical therapists to use in introducing the influences of emotions and spirituality into CBP support. From a broader perspective, the significance of this study may be that it suggests the need for an entirely new healthcare provider specialty. In this new specialty, “integral” therapists would identify skills taken from numerous disciplines to match the need for integral healthcare providers to address the many mechanisms that influence CBP.

Researcher’s Assumptions I credit a good deal of my healing to the introspective nature of my initial yoga experiences that unearthed so many of my own unexamined assumptions. The conflicts between those unexamined assumptions and my professed beliefs 9

generated much of the pain I carried in my low back. (i.e., I am in charge; I am in control; I am responsible [vs. I am an instrument of a higher power]; everything is for a purpose; trust and have faith, etc.). I became aware of numerous assumptions I held about CBP in general, the shortcomings of the delivery system in which I practice, and the experiences of self-care for my CBP that were part of my personal history. I identified assumptions that I held as the facilitator and participant in my research study. The first was: CBP is a complex phenomenon that is almost never the result of a single “bad” part that needs fixing. I assumed that not only was the entire spectrum of the individual’s experience—body, mind, emotions, and spirit—affected by CPB, but also that their entire socioeconomic network of relationships was affected as well. The pain both affects and is affected by that larger web of relationships. The second assumption was: knowledge and culture is developed primarily in community. This is a new assumption for me that has replaced the “lone individual” model that is dominant in our culture. When new insights and interpretations are not shared or validated in a community setting, the depth and quality of inquiry is significantly limited. Third, I assumed that practical action must accompany any healing encounter. If the encounter yields only theory or actions that cannot be assimilated into one’s personal life context, then healing may be blocked or limited.

The fourth assumption was: no individual healthcare practitioner can “know” for certain the answers to another individual’s challenge with chronic spine pain. While expertise, education, and manual facilitation do support healing, ultimately individuals need to find their own meaning and engage in their own healing actions. The complexity of each participant’s circumstances cannot be fully known by another, and even if it could be, their meaning and purpose cannot be fully understood. Fifth, I assumed that people with chronic spine pain sincerely want to be relieved of their suffering and are not as a rule “working the system” In the right environment, individuals are motivated to learn, put forth effort, and take appropriate risks. The current healthcare culture has failed to create such an environment, and if it did, the caregivers would often be personally ill equipped to maintain such an environment. My sixth assumption was that most physical therapists and many occupational therapists lack training in the integral skills necessary for this type of environment. Most have been trained in and maintain a mechanistic modern view of healthcare and therefore have difficulty conceiving of the more integrated format I am proposing as a clinically viable option of delivery. Of those who can, an even smaller percentage are actively engaged in their own personal integral practice; they are therefore limited experientially in facilitating such a program. Subsequently, a broad degree of education and experience will be necessary before the process will be widely embraced by the professions.

Finally, I assumed that back pain is a socially acceptable form of distress to manifest in our culture that often represents imbalance across a number of other aspects of the individualâ&#x20AC;&#x2122;s experience. I realized from my own healing that my fear and conflict with my spiritual concerns over safety and trust are a primary cause of my pain. I continue to experience this relationship when I feel threatened or reverted to old thought patterns.

CHAPTER II: LITERATURE REVIEW

This literature review begins with background information on chronic back pain (CBP). Following the background information, the literature review then focuses on group approaches as a strategy to treat CBP. For the purposes of this study the strategies for treating CBP have been divided into two categories: 1) individual approaches; and, 2) group approaches. The following are my definitions for these two categories. In individual approaches, the person with CBP is treated individually by providers without interaction with other people with CBP. In group approaches, more than one person with CBP is treated at a time by the providers and there is the possibility for interaction between the individuals. The literature review will focus on group approaches, but a statement on the individual approaches is warranted. The primary focus of group approaches is back schools, including the how and why the various models developed, and their respective outcomes. The limited and variable nature of the outcomes of these back schools establishes the need for a new group approach that can accommodate the complexities of chronic back pain. After reviewing the limited effectiveness of the results of the back schools and other group approaches, this literature review then examines the assumptions underlying the back school approaches. One significant assumption is the quantitative perspective that shapes research and current care. This literature review illustrates the influence the quantitative perspective has on shaping research methods and study design for CBP, and on the back school approaches. The constraints of the quantitative 13

perspective illustrate the limitations of the quantitative approach in addressing the complexities of CBP. The literature review finishes by examining two recent research studies where elements of a broader perspective of CBP yielded encouraging results. The introduction of these two studies suggests elements of inquiry that helped to form the purpose of this study, which is to introduce a pedagogy and a new group approach based on providing a process for addressing the complexities of current CBP knowledge.

Background Back pain is an integral part of most human lives and causes different degrees of suffering and disability. Back pain is second only to the common cold as a cause of lost work time; it is the fifth most frequent cause for hospitalization and the third most common reason to undergo a surgical procedure (Manek & McGregor, 2005). Back pain can interfere with activities that range from basic activities of daily living such as walking and dressing to work-related functions. Pain is not the only factor that determines disability in patients with back pain. In fact, the intensity of the pain and the degree of disability does not correlate well. The level of disability is associated with multiple factors including personal, psychosocial and occupational factors (Kovacs, et al.â&#x20AC;&#x2122;s, 2004). While biomechanical factors do influence pain, Kovacs, et al.â&#x20AC;&#x2122;s review (2004) found that psychosocial factors have more of an influence on the development and duration of disability. The complexity of the personal, psychosocial and occupational factors that lead to chronic back pain would seem to defy any simple solution. Many professions are concerned because the exact cause of most CBP cannot be 14

identified and there continues to be increasing significant consequences of longterm or permanent disability for those with CBP (Manek & McGregor, 2005). The following summary illustrates the breadth and recalcitrance of the problem of CBP. The difficult experience of CBP and the escalating costs associated with it are challenges that continue to grow in modern society. CBP is often noted to constitute one of the most difficult and costly medical problems in developed countries (DiFabio, 1995; Hall & Hadler, 1995; Heymans, et al., 2005; Linton & Kamwendo, 1987; Quittan, 2002). The costs of treating CBP reached a minimum of $50 billion (U.S. dollars) in the United States in the year 2000, and continuing to grow at least 7% per year since 1995 (Straus, 2002). In the United States, the combined costs of medical expenses, compensation, lost earnings, and lost productivity for individuals with acute and chronic back pain has continued to grow with a recent estimate of these direct and indirect costs of intervention for CBP being $100 billion a year (Anagnostis, Gatchel, & Mayer, 2004). Over the past 40 years, despite multiple approaches and types of intervention, the reduction of chronicity of pain and disability continues to constitute the main challenge for back pain management (Jousset, et al., 2004). There are multiple evidence-based guidelines for treating back pain worldwide that have indicated how acute low back pain should be managed (Bogduk & McGuirk, 2002). It is now accepted that such medical management should include effective communication with the patient. The communication should provide explanation and assurance, allay fears, and instructions to promote

activity and avoid passive therapies (Bogduk, 2004). Providers and patients can expect that while 85% of the population will at some time experience acute low back pain, better than 70% will become pain-free, with a recurrence rate of less than 25% (McGuirk, King, Govind, Lowry, & Bogduk, 2001). The guidelines for the intervention for chronic back pain are entirely different than they are for acute or subacute low back pain. The problems begin in defining what chronic back pain is. CBP has been variably defined including episodes lasting more than three months, with and without radiating leg pain, more than three episodes and many other variations (Heymans, et al., 2005). Bogduk and McGuirk (2002) define chronic back pain as pain that has persisted for longer than 3 months. Besides pain, individuals with chronic back pain usually suffer physical disabilities and psychological distress and are often depressed and unable to work (Bogduk & McGuirk, 2002). Manek & McGregor (2005) noted that the literature regarding the long-term course of CBP is confusing because of variations in definitions of what constitutes CBP as well as a lack of what constitutes return to work, recurrent episodes, pain levels and other outcome parameters. Various outcome measures have been studied (pain, disability, sick leave, and medical consultations) (Manek & McGregor, 2005). Data has shown that a considerable proportion of patients with low back pain continue to experience both symptoms and varying degrees of disability at 4 years, even though they were not necessarily seeking care at that point (Burton, Waddell, Tillotson, & Summerton, 1999). Manek and McGregor (2005) noted that psychological distress (in the form of depressive symptoms) emerged as the

strongest single baseline predictor of four-year outcomes pain levels and return to work, and greatly exceeded the influence of pain intensity as a predictor. The literature review indicates that the term and experience of chronic back pain encompasses far more than a simple pain as it affects so many aspects of the human experience beyond the sensation of pain. The next sections look at the degree of success current medical practices have had in addressing CBP with individual and then group approaches.

Individual Approaches There are many individual approaches spanning a broad range from a simple back care educational handout to complicated major surgery with disc replacement. Bogdukâ&#x20AC;&#x2122;s (2004) review offers a detailed summary of the evidence supporting each of these individual approaches. The individual approaches covered included drugs, exercise therapy, braces, biofeedback, massage, manipulation, traction, antidepressants, behavioral therapies, and surgery. In summary, the evidence for individual approaches to CBP is variable and at best mixed, with some benefits from the individual approaches but none of them standing out as a best evidence approach for CBP (Bogduk, 2004).

Group Approaches There have been group approaches for people with CBP for over thirty years (Maier-Riehle & Harter, 2001). How those approaches developed, what their objectives have been, and some of the outcomes are reviewed next. The

structure and organization of these group approaches reveals the assumptions and perspectives of the providers at the time the approaches are developed. After reviewing some of the group approaches and their outcomes, the literature review will then address in detail what forces have shaped, and still are shaping the evolution of the group approaches. Most group approaches were known as some variant of a â&#x20AC;&#x153;back schoolâ&#x20AC;? (Maier-Riehle & Harter, 2001). The group approaches were applied to different target groups including workers without back problems (primary), people with a recent onset of back pain (secondary), and people with chronic disabling back pain (tertiary) [Mayer, et al., 1995]. The nonoperative treatment for group approaches has been divided into three groups: 1) primary rehabilitation/prevention for those at risk to develop back pain; 2) secondary rehabilitation for care of acute low back pain performed for 0-12 weeks after the occurrence of back pain for the purpose of recovery and prevention of recurrence; and 3) tertiary rehabilitation performed by a multidisciplinary team approach (orthopedics, neurology, physical therapy, psychology, and occupational therapy) for those with back pain lasting over 12 weeks (Mayer, et al. , 1995). Tertiary rehabilitation is to prevent or ameliorate permanent disability for the person who already suffers the effects of chronic disability and deconditioning. Based on Mayerâ&#x20AC;&#x2122;s classification, individuals with CBP should be managed with either secondary or tertiary rehabilitation (Mayer, et al.). The focus of the literature review will be limited to the secondary and tertiary rehabilitation approaches because they address the CBP population.

The History and Models of Back Schools An article by Maier-Riehle and Harter (2001) offers a concise history of back schools. Maier-Riehle and Harter reported that the original Swedish Back School was developed by Marianne Zachrisson-Forsell in 1969 near Stockholm. The Swedish Back School was intended to reduce the pain and prevent recurrences of episodes of low back pain (Ero, 1997). The Swedish Back School was based on the assumption that pain in most patients is exacerbated by mechanical stresses and that educational efforts should be directed toward compensation of these stresses (Lankhorst, et al. as cited in Heymans, et al., 2005). The Swedish Back School consisted of information on anatomy, biomechanics, optimal posture, ergonomics, and back exercises (2005). Back schools were also being developed in the USA, including the California Back School which dedicated more than 90% to its class time to exercise/ergonomics/conditioning intensives (Mattmiller, 1980). Hallâ&#x20AC;&#x2122;s (1980) program with the Canadian Back Education Units added attempts to change patientsâ&#x20AC;&#x2122; attitudes by trying to have the patients assume greater personal responsibility for their health status. The addition of attitude change to biomechanical education in patients was to be accomplished through group education presented in four separate sessions (units) by various specialists (physiotherapists, orthopedists, and psychologists/psychiatrists). Each specialist individually presented various modules within each unit and the units were made up of modules that were covered by the respective specialist. The instruction

modules included spinal anatomy, body mechanics, flexion exercises, pain and stress management, and general relaxation techniques (Hall, 1980). Of the four units, one entire unit dealt with the psychological aspects of back pain, and part of the final class was led by a psychologist teaching relaxation exercises. Hall’s (1980) model included psychological education in over 25% of the curriculum. Keijsers, Groenman, Gerards, Van Oudheusden, and Steenbakkers (1989) of the Maastricht Back School in the Netherlands later expanded on the inclusion of psychological factors and relaxation in back schools. The Maastricht Back School consisted of eight classes, the final two of which were review/booster classes. Of the six classes containing new content, only the fourth focused on exercise and ergonomics while four of the six lessons were on pain and psychological factors. The class was expanded on to earlier back school activities to include cuing-trained relaxation responses to the patients’ environmental stimuli and training in how to reduce anxious tension generated by expectations and labeling. The content and length of back schools continued to change in the 1990s with variations of emphasis based on multiple new factors discovered to affect the complex nature of CBP. Functional restoration, originally introduced by Mayer, et al. (1987) was often featured in the back schools in the ‘90s. Functional restoration emphasized function and return to work over pain relief, bringing multiple professionals including occupational therapists, psychologists, and exercise physiologists in a residential outpatient setting (Jousset, et al., 2004). The American Back School (Schenk, Doran, & Stachura, 1996), and the Active Back

School (Glomsrod, Lonn, Soukup, & Larsen, 2001) focused on postural techniques, ergonomics and strength training. The back school programs most recently reported in the literature had varying elements of inpatient and outpatient care of acute and chronic back pain; these were most often integrated in a multidisciplinary team and multimodal treatment approach (Heymans, et al., 2005). Heymans, et al. reported that back schools utilized various professionals from different disciplines including physicians of differing specialties (orthopedists, neurologists, physiatrists, psychiatrists, etc.), physical and occupational therapists, psychologists, exercise physiologists, and athletic trainers. The modalities offered in present day back schools are not limited to education only, but may include specific exercise, relaxation training, counseling, and ergonomic training (Heymans, et al., 2005). The range of professionals and modalities included in the back schools reflected the dominant quantitative perspective that has shaped back school design and pedagogy. The literature reviewed has addressed the more easily quantifiable physical and psychological factors in individual and group approaches for treating CBP; however, there was not a single mention of a spiritual approach to address CBP for either the individual or group approaches. The literature review also found no discussion of the impact of CBP on the individualâ&#x20AC;&#x2122;s spirituality. Some elements of spirituality are addressed under psychosocial categories such as beliefs and attitudes (Burton, Waddell, Tillotson, & Summerton, 1999; Crombez, Vlaeyen, Heuts, & Lysens, 1999; Turner, Jensen & Romano, 2000), but the words spiritual or spirituality were absent. The effects and functional limitations CBP

has on the personâ&#x20AC;&#x2122;s lifestyle, emotions, mental health, and spirituality would seem to require more focused inquiry in this area by providers, yet these have not been addressed in the research literature reviewed. Todayâ&#x20AC;&#x2122;s varied back school models are a reflection of the ongoing evolution of the constantly changing knowledge of CBP. Before looking at how back schools differ, this literature review will examine the shared similarities between back schools, their differences, and their outcomes.

Similarities among Back Schools There are shared commonalities among the back schools based on the underlying assumption that CBP can be treated effectively through an educational process. The educational process utilized in most back schools is to have experts provide the information and skills that participants lack. The number of experts needed has increased as our understanding of the complexity of CBP has unfolded. The back schools reviewed had a number of characteristics in common. The back schools consisted of a series of classes in which a group of similarly classified patients with spine pain were brought together and taught by an expert(s) in anatomy, biomechanics, activities of daily living (ADL) instruction, exercises, psychological strategies to deal better with back pain, and self-care techniques (home modalities, use of supports, adaptive equipment, etc.). In all of the studies reviewed, the back schools determined the curriculum ahead of time, with modifications allowed for the duration and repetition of certain activities based on individual tolerance of the activity. Two of the back schools offered

psychological and social counseling services as a part of intensive residential (allday intervention) programs where the participants went to a rehabilitation center daily for several weeks (Bendix, Bendix, Busch, & Jordan, 1996; Jousset, et al., 2004). In none of the back schools reviewed was it reported that the interactions or group dynamics of the participants themselves was considered a source to gain new information, perspectives, or skills through the group interaction. Information and skills were always presented by the instructors as the experts; no studies were found in which participants offered programming ideas or content to the educational process. Beyond these shared characteristics, back schools have differed in many aspects.

Differences among Back Schools As noted earlier, as the complexity of CBP unfolded, the back schools modified and broadened their approaches. These changes generated the present day multiplicity of back school approaches. The differences in approaches were in response to two major influences. First, programming in the back schools needed to expand to create interventions that could affect the increased number of variables known to affect CBP (biomechanics, stress, work conditions, fear, deconditioning, etc.). Secondly, new outcomes measurements were adopted which required more new programming. The back schools differed in a substantial number of parameters; these differences must be considered when evaluating the effectiveness of back schools (DiFabio, 1995; Hall & Hadler, 1995; Heymans, et al., 2005; Linton &

Kamwendo, 1987). First, the content and length of back schools differed from single to multiple classes, ranging from a “mini” back school that teaches only body mechanics (Indahl, Haldorsen, Holm, Reikeras, & Ursin, 1998) to a multidisciplinary team approach encompassing many professionals, including orthopedic surgeons, physiatrists, neurologists, psychiatrists, physical therapists, and occupational therapists (Bendix, et al., 1996; Jousset, et al., 2004). Second, curricula varied widely in terms of participants’ level of involvement. The percentages range from nearly 100% active participation of participants in functional restoration programs (Bendix, et al.,1996; Jousset, et al., 2004) to the 100% entirely passive instruction in a mini-back school (Stankovic & Johnell, 1990). In most of the back schools, levels of active participation fell somewhere between these extremes. Thirdly, the participants varied widely, with some back schools including participants involved with workers’ compensation, litigation, or disability insurance, while at other times these individuals were excluded (Heymans, et al., 2005). The settings varied as well, ranging from hospital settings (Hall, 1980; Shirado, et al., as cited in Heymans, et al., 2005) and primary care settings (Keijsers, et al., 1990), to employer/insurer-funded back schools (Bendix, et al., 1996; Jousset, et al., 2004; Leclaire, et al., 1996). Sometimes the setting was not even reported (Keijsers, et al. 1989; Lankhorst, et al. as cited in Heymans, et al., 2005). Finally, the back schools differed in how outcome efficacy was measured, including: pain intensity, frequency of analgesic use, return to work, sick leave,

disability, frequency of hospitalization and therapeutic exercises, patientsâ&#x20AC;&#x2122; satisfaction, and psychological status. Not only have the outcomes been varied, but the studies have taken place in different countries (including Sweden, Canada, the Netherlands, France, the United States, and Japan), medical health systems (socialized, workmanâ&#x20AC;&#x2122;s compensation, private/commercial) and cultures (Hall, 1980; Keijsers, et al., 1989; Lankhorst, et al. as cited in Heymans, et al., 2005; Mayer, et al., as cited in Heymans, et al., 2005; Shirado, et al., as cited in Heymans, et al., 2005; Sobaszek, et al., 2001). The heterogeneity of these cultures, health systems, and individual participants were additional factors that confounded analysis. The most recent review of back schools was limited to a qualitative best-evidence synthesis, which has been summarized in the following findings reported in this review (Heymans, et al., 2005). The synthesis gives clinicians no clear guidance on the effectiveness of back schools and suggests the need to re-examine the purpose of back schools in future studies.

Outcomes As back schools evolved, the outcomes measured by the back schools changed to reflect their areas of focus and the expanded understanding of the complexities of CBP. Back schoolsâ&#x20AC;&#x2122; purposes lie in educating patients on the nature of their low back disorders, and helping them to form an active lifestyle and a positive attitude (Van Tulder, Koes, & Bouter, 1997). Practicing therapeutic exercises and learning correct body mechanics was emphasized in many back schools (Turner, 1996). Maier-Riehle & Harter (2001) reported that the goals or

anticipated outcomes of the back schools vary but usually include the reduction of existing back pain and the prevention of recurring back pain, and correspondingly, a decrease in the utilization of medical services, increased function, and a reduction of healthcare related costs. Some back schools have demonstrated effectiveness in addressing various outcomes. The effectiveness of back schools spanning the past 30-plus years has been the subject of many reviews over the years (Cohen, et al., 1994; DiFabio, 1995; Hall & Hadler, 1995; Heymans, et al., 2005; Linton & Kamwendo, 1987). The differences in back schools and how they measured outcomes made direct comparisons between back schools difficult. The reviews have compared back schools to other interventions for CBP including back schools compared with other treatments for CBP; back schools compared with waiting list controls and placebo; back schools in occupational settings compared to other treatments; and, back schools in occupational settings compared to other waiting list controls and placebo. Because this is the organization of reporting utilized in the most recent review (Heymans, et al., 2005) this literature review will report the summaries of the synthesis in the same manner. The levels of evidence utilized by Heymans, et al. (2005) were: strong evidence—provided by generally consistent findings in multiple high-quality random controlled trials (RCTs); moderate evidence— provided by generally consistent findings in one high-quality RCT plus one or more low quality RCTs, or by generally consistent findings in multiple low quality RCTs; limited or conflicting evidence—only one RCT (either high or low quality) or inconsistent findings in multiple RCTs; and, no evidence—no RCTs.

Back schools compared to other treatments for CBP. Heymans, et al. (2005) found moderate evidence suggesting that back schools are more effective for pain and function than other conservative treatments (exercises, spinal or joint manipulation, myofascial therapy, and various instructions or advice). Back school was only more effective when the patients with CBP are from the general public and primary or secondary care, but not effective if the patients CBP was work or accident related (Donchin, Woolf, Kaplan, & Floman, 1990; Harkapaa, Jarvikoski, Mellin, & Hurri as cited in Heymans, et al., 2005; Klaber Moffett, Chase, Portek, & Ennis, 1986; Penttinen, et al., 2002; Postacchini as cited in Heymans, et al., 2005). There is moderate evidence that there is no difference in long-term pain and functional status between patients with CBP receiving back school and patients with CBP receiving other treatments (Donchin, et al., 1990; Harkapaa, et al. as cited in Heymans, et al., 2005. All of the studies Heymans, et al. reviewed (Donchin, et al., 1990; Klaber Moffett as cited in Heymans, et al., 2005; Harkapaa, et al. as cited in Heymans, et al., 2005; Penttinen, et al., 2002; Postacchini as cited in Heymans, et al., 2005) utilized combinations of modified Swedish back schools, ergonomic instruction, back exercises and relaxation exercises and compared the approach to some form of the conservative treatments listed above. Back schools compared to waiting list controls and placebo. There is conflicting evidence on the effectiveness of back schools compared to waiting list controls or placebo interventions on pain, functional status, and return to work (short, intermediate, and long-term follow up) for

patients with CBP. The studies reviewed compared the back school approach to either a group that had been put on a wait list or treated with a placebo (Dalichau, et al. as cited in Heymans, et al., 2005; Donchin, et al., 1990; Keijsers, Groenman, Gerards, Van Oudheusden, & Steenbakkers, 1989; Keijsers, et al., 1990; Lankhorst, et al. as cited in Heymans, et al., 2005; Linton, Bradley, Jensen, & Spangfort, 1989; Lonn, Glomsrod, Soukup, Bo, & Larsen, 1999; Postacchini, Facchini, & Palieri, as cited in Heymans, et al., 2005). Lonn, et al. (1999) found positive long-term outcomes on functional status and return to work, but two other studies did not find any long-term differences (Donchin, et al., 1990; Lankhorst, et al. as cited in Heymans, et al., 2005). While there was a positive long-term outcome in one study (Lonn, et al., 1999) there were some questions about the sample population of the study. First, the participants were solicited from the media raising concerns about the randomness of the sample. Another question was regarding the chronicity of the recruited participants who were required to have had only a single previous episode of resolved low back pain while Donchin, et al. (1990) required at least three previous annual episodes of low back pain. Not withstanding the concerns about Lonn, et al.â&#x20AC;&#x2122;s (1999) study sample, the search for a predictive variable(s) leaves only mixed results compared with a wait list or placebo (Heymans, et al., 2005). Back schools in occupational settings compared to other treatments. Back schools have been used in occupational settings in order to promote earlier return to work and to control employer and insurersâ&#x20AC;&#x2122; costs for injured workers with CBP (Donchin, et al., 1990; Harkapaa, et al. as cited in Heymans, et

al., 2005; Penttinen, et al., 2002). Heymans, et al.â&#x20AC;&#x2122;s review found moderate evidence that a back school in an occupational setting is more effective than other treatments for patients with CBP for pain and functional status in the short and intermediate term. In the long-term, Heymans, et al. (2005) found conflicting evidence that back school was more effective than other treatments. Back schools in occupational settings compared to waiting list controls and placebo. Three studies examined the effectiveness of back schools within occupational settings (Dalichau, et al., 1999; Donchin, et al., 1990; Linton, 2000). There is moderate evidence that on a short- and intermediate-term follow up a back school is more effective than waiting list controls for patients with CBP for pain (pain scales and incidences of pain episodes), and return to work (lost work days and percent of lost work days). There is limited long-term evidence that there is a difference in the incidence of low back pain episodes between back school and waiting list controls for patients with CBP (Heymans, et al. 2005). It is discouraging that after 30 years of refining emphasis, curricula, settings, and outcomes to have reviewers conclude that most of the randomized controlled trials (best evidence) were of low methodologic quality and did not score sufficiently on clinical relevance (Heymans, et al., 2005). In their first paragraph, Heymans, et al. state that they could not â&#x20AC;&#x153;identify strong evidence for any type of back school treatmentâ&#x20AC;? being more effective than other forms of treatment for CBP. Group approaches of back school education for people with CBP have not demonstrated strong evidence of effectiveness, and this

circumstance calls for significant reassessment and restructuring of the back schools after over 30 years of trials. Other groups. This literature review also looked to the literature for group approaches that were substantially different from the back school models reviewed above. In the review of the literature no published studies were found that utilized the group participants working together to discoverâ&#x20AC;&#x201D;as a groupâ&#x20AC;&#x201D;new information on how to live with CBP. No group approaches were found that allowed the participants to modify the content of the group curriculum. None of the reviewed studies assessed the individual needs of the participants that had entered the school and then modified the curriculum to match those needs. A few studies addressed aspects of participant discussion and contributions. Kabat-Zinn (1982) emphasized an introspective or mindful approach, having participants commit to homework and journaling, and then sharing those insights with the group that resulted in statistically significant reductions in measures of present-moment pain, negative body image, inhibition of activity by pain, symptoms, mood disturbance, and psychological symptomatology, including anxiety and depression. KabatZinn (1982) also report pain-related drug utilization decreased and activity levels and feelings of self-esteem increased, with all of these changes lasting through a 15-month follow up except present moment pain levels. Ersek, Turner, McCurry, Gibbons, and Kraybill (2003) shifted the emphasis of chronic pain education from a biomechanical model of ergonomic and physical reconditioning to a group interactive process model of self-management of chronic pain [in elderly

persons]. The group of 45 subjects was mostly women (86%); 76% had back pain and 42% suffered from neck pain. The self-management group showed significantly greater pre- to post-treatment improvement in physical role function and characteristic pain intensity, but no significant differences were found between the groups on measures of pain-related activity interference, depression, and pain-related beliefs. The changes in approach toward group self-management included education about pain as well as training in the following areas not seen in the other studies: group support and interaction led by a trained group facilitator, communication with health care providers, and other pain coping skills, such as positive coping self-statements (2003). In the review of the literature no studies were found of group approaches to CBP that utilized a collaborative inquiry methodology (Heron & Reason, 1997). The collaborative inquiry methodology is a qualitative form of action research that will be used in this study and described in detail in Chapter III. A more thorough review of the assumptions of the quantitative methodology that has formed back schools to date will support the need to consider the collaborative inquiry method.

The Assumptions Underlying Back Schools in Group Approaches This section of the literature review examines what assumptions created the back schools and what constraints such assumptions may have on understanding of CBP. The literature review also summarizes the current understanding of the complexities of CBP. The focus of the back school

movement in the literature has been guided by assumptions that may no longer completely address the known complexities of CBP and a new set of assumptions may be needed to address new thinking about such a complex problem. If the constraints of the assumptions underlying back schools are limiting their effectiveness in serving the patients that attend them, then to paraphrase G. K. Chesterton, “It isn’t that we can’t see the solution. It is that we can’t see the problem” (Chesterton, 1986).

The Review Only one study of CBP was found in the literature review that utilized a qualitative methodology as a group approach (Walker, Holloway, & Sofaer, 1999) all other group approach studies for CBP reviewed utilized a quantitative methodology. Montuori (2005) pointed out that the fundamental cornerstone of the Western knowledge base, including medical knowledge, is the quantitative method. Montuori stated that this quantitative form of inquiry is both reductionistic and disjunctive in nature, arriving at increasingly smaller and smaller subsections of knowledge about the subject at hand. These subsections have resulted in the numerous outcomes measurements of CBP that leaves clinicians and consumers with limited and conflicting evidence about the effectiveness of group approaches. The search for the exercise, psychosocial intervention, curriculum, medication, etc., has left the literature with very many “parts” of understanding of the nature of CBP, but no single approach has successfully “put Humpty Dumpty together again.”

According to Montuori (2005), the Western way of organizing thought has constructed a reality of both knowledge-producing institutions (i.e., universities, insurance companies, and professional associations), and providers of care. Both the institutions and the providers endeavor to maintain their individual identities and to protect their own “turf.” In studying CBP, the Western way of organizing thought has yielded a wealth of valuable data “pieces,” but in doing so may not address the whole of CBP. This next section of the literature review will summarize how dominance of the quantitative form of inquiry came to be; the current understanding of the complex nature of CBP; and, the limitations this way of organizing thought has created in understanding the complex nature of CBP.

The History and Development of the “Parts” View In the West, quantitative methodology has been the dominant form of scientific inquiry the past 400 years (Montuori, 2005). The quantitative form of scientific inquiry has brought together concepts and data in the form of ideas and observations about human life. Scientists sought to establish a correspondence between what they observed and their conceptual understandings of the way things are (Babbie, Halley & Zaino, 2000). In quantitative methods when scientists measured or quantified concepts that captured variations among people, they shifted terminology from concepts to variables to allow for object manipulation within an experimental framework. The outcome of this object manipulation was to presumably arrive at an understanding of relationships from a causal perspective in order to predict future events, (i.e., A influences B to result

in C therefore A causes C to occur) (Babbie, Halley & Zaino, 2000). The findings about the pressure ratios in the intervertebral disc under different mechanical strains (Nachemson, 1960; 1966), suggest that back pain was a consequence of incorrect body posture or movements and is said to have stimulated the development of back schools (Maier-Riehle & Harter, 2001). In the medical and popular literature (Sarno, 1999; Bogduk, 2004) there has been a tendency to focus on finding and fixing the offending part, either literally or as an aspect of human experience (physical, social, emotional, etc.). The back schools evolved beyond the initial focus on mechanical strain to adopting as earlier noted mental health approaches, multiple disciplines, and multiple modalities. The evolution of back schools has generated the numerous outcome measurements listed, frustrated comparisons and produced a limited number of high-quality RCT studies (Heymans, et al., 2005). How the quantitative evolution of back schools happened is the subject of the next section of the literature review.

How the â&#x20AC;&#x153;Partsâ&#x20AC;? View Has Limited Understanding of CBP The accepted assumption of the quantitative inquiry of CBP has been that if researchers identify what variable(s) within their hypothesis created or sustained CBP, then what was needed for a successful outcome would be to modify that variable(s) (Babbie, Halley, & Zaino, 2000). The relationships discovered in a quantitative inquiry are probabilistic in nature and theoretically allow the inquirer to make predictions about similar samples of individuals. The logic and power of probability sampling derived from such a methodology

produced the various studies’ ultimate purpose: generalization and prediction (Patton, 2002). Every study reviewed sought this predictability. The tendency by researchers and consumers to seek predictability through quantitative inquiry may be serving as an unseen bias (Morin, 2005) that has obscured the development of new forms of back schools. The bias for predictability has, according to Beaulieu (2003), led to the methodological tail wagging the theoretical dog, or a form of methodolotry that is not new. Locking inquiry into quantitative methodology without re-examining the assumptions behind the quantitative methodology contributes to the way that researchers are “seeing the solution, but still not seeing the problem” (Chesterton, 1986). Shekelle and Delitto (2005) raise the concern that an unexamined pursuit of predictability where the methodology would require the same intervention being applied to everyone regardless of their presentation has thus far generated “trivial” effects of therapy. Beaulieu (2003) uses the term paradigmatic velvet rut to describe the phenomenon of when entire disciplines or groups of disciplines metaphorically spin their collective research wheels because the assumptions that form the basis for the discipline’s understanding are left unexamined. The search for predictability arises from the realist philosophy that forms the foundation for the quantitative method (Fay, 1996). This assumption of predictability is an example of the phenomenon of a paradigmatic velvet rut that has occurred in the disciplines that utilize the quantitative methodology. The narrowed scope of focus of the quantitative method has fallen short of addressing the complexity of treating patients with CBP. Some specific examples of how the complexity has

not been addressed in the clinic, in the research settings, and for consumers will illustrate the effects of narrowing the scope of focus to just a quantitative methodology.

Evidence Underlining the Need to Address the Complexity of CBP The Guide to Physical Therapy Practice (2001) is the standard of care for physical therapists and describes disability as multifactorial. The Guide stresses the need to address multiple factors when working with a patient. The need to discover these multiple factors influencing disability for the individual in a oneon-one treatment models is accepted practice. This literature review gave no indications that the intake process, curricula or content of any of the back schools had the sensitivity to identify and address the multiple individual factors that influence disability. In back schools, once the individual has cleared the inclusion criteria, there is a theoretical assumption of homogeneity of the group. This assumption of homogeneity is necessary, as quantitative studies operate on statistical averages and to vary interventions, subjects, and variables would weaken or destroy the predictability of the studies (Babbie, Halley, & Zaino, 2000). Morin (2005) described how the quantitative methodology form of inquiry can create an unexamined assumption that would have providers presuming to know the multiple factors affecting the patientsâ&#x20AC;&#x2122; back pain without querying the patients, or at best have selected a generalized curriculum to be representative of the average student with CBP. More specific examples will further illuminate the limitations of the quantitative perspectiveâ&#x20AC;&#x2122;s ability to fully address the

complexities of CBP and substantiate the need for additional perspectives in addition to a quantitative approach to designing future back schools.

Examples in the Clinic The limitations of the quantitative methodology in clinical situations have been noted in the literature. This section of the literature review will examine examples that call for specificity of treatment for individuals, behavioral interventions, systems’ effects, and focus on bad parts. Individual approach to treatment. In the clinic, the use of an average treatment or a tear-off sheet of back exercises is analogous to the approach of standardized back school curriculums and such treatment is considered substandard care (Kerssens, Sluijs, Verhaak, Knibbe, & Hermans, 1999). Research is needed to help clinicians to identify specific demographic, medical, and psychosocial factors that are important for tailoring interventions to the individual (Åsenlöf, Denison, & Lindberg, 2005; Edwards, Jones, Carr, Braunack-Mayer, & Jensen, 2004; Kerssens, et al., 1999). Beyond identifying multivariate factors for interventions (satisfying predictability of interventions), there must also be an understanding of the complex and dynamic relationships between the multivariate factors that occur in the improvement to be demonstrated in outcomes for CBP studies (Ersek, et al., 2003). Ersek, et al. note that an understanding of the isolated factors is insufficient in the clinic if the clinician did not also know how each factor affects the process of the improvement through its multiple relationships with other factors.

Behavioral interventions. In the past 15 years behavioral interventions have been prevalent in the CBP literature (Fritz & George, 2000, 2002; McCracken & Turk, 2002; Peters, Vlaeyen, & Weber, 2005). The main assumption of a behavioral approach is that pain and disability are not only influenced by somatic disease, but also by psychological and social factors (Peters, Vlaeyen & Weber, 2005). CBP is now understood to be not only a physical problem, but the individualâ&#x20AC;&#x2122;s experience of CBP also depends on the patientâ&#x20AC;&#x2122;s attitudes and beliefs, psychological distress, and illness behavior (McCracken & Turk, 2002). It is proposed that future interventions for CBP will need to manage any underlying somatic disease, but should not be primarily focused on removing the disease, since most CBP has no identifiable disease process (Manek & McGregor, 2005). The treatment of CBP in the clinic will also need to influence the reduction of disability through the modification of environmental contingencies and cognitive processes (Peters, Vlaeyen, & Weber, 2005). The modification of these environmental and cognitive systems are the measured correlates of emotional experiences: behavior, cognitions, and physiologic reactivity. The understanding of the relationship of emotions and CBP has been progressively addressed in the literature in the past 15 years (Van Tulder, Malmivaara, Esmail, & Koes, 2000). Physical therapists have been urged to identify patients who have an increased likelihood of depression. To facilitate a more appropriate management, the patients at risk for depression should be referred to a medical practitioner or clinical psychologist for definitive diagnosis and intervention (Haggman, Maher,

& Refshauge, 2004). Data has suggested that even when patients with spinal pain are identified by medical practitioners as being depressed, a large proportion of those patients do not receive any particular intervention or help for their depression (Cohen, Nicholas, & Blanch, 2000). A study that surveyed physical therapist management of CBP in North America and Europe indicated that there was no mention of screening for depressive symptoms in current practice, and that physical therapists do not adequately screen for depressive symptoms in their patients with CBP, even though depression is a common symptom among their patients (Haggman, Maher, & Refshauge, 2004). Haggman, Maher, and Refshauge state in their discussion that only when the patients are classified with moderate or severe depression should they be considered for psychological referral. Haggman, Maher, and Refshauge make no mention of the need for therapists to modify the physical therapy interventions of patients classified with low risk of depression. While Haggman, Maher, and Refshauge and The Guide to Physical Therapist Practice (2001) recognize depression as important, by tradition depression is a mental health problem and is viewed as a separate part from the physical problem of the CBP. Depression may soon be better identified in the clinic by physical therapists, but in the literature reviewed, no ties to the influences on depression of physical movements on depression beyond aerobic exercise has been identified for the physical therapist to address depression as a common component of CBP (Roelofs, Boissevain, Peters, de Jong, & Vlaeyen, 2002).

Lost in the system. Clinicians and researchers have tried to gain a better understanding of the origins and nature of the negative attitudes exhibited by many back pain patients (Walker, Holloway, & Sofaer, 1999). Walker, Holloway, and Sofaer note that there are health care systems designed to treat or support those who are ill or disabled, but in their qualitative study a prominent emergent theme was about being lost “in the system.” It was reported by the participants in the study (Walker, Holloway, & Sofaer) that they became entrapped within the medical, social security and legal systems. This is an example of how the institutions that are created to manage and address CBP are limited by the bureaucratic classification standards (prediction requirements) negatively influencing intervention for CBP. These medical, social security and legal systems effectively rendered participants powerless, helpless and angry. The result is that clinicians now need to determine how or if they as individual providers can even manage patients with negative attitudes generated by larger systems’ effects of the institutions designed to address CBP (Walker, Holloway, & Sofaer, 1999). The literature indicates that anger aggravates back pain (Carson, et al., 2005), but does not answer what can be done if the source of the anger is the system providing or directing care such as the medical, social security or legal systems. Focus on the “bad part.” Insurers, patients, and clinicians insist on labeling a structure for CBP (Cherkin, Boissevain, Peters, de Jong, & Vlaeyen, 1996). The type of information presented to participants in back schools for CBP has been based on a medical

model or structural pathology model, which can be conducive to psychological changes in the participants that may promote CBP (Waddell, 1998). The possible negative effect of traditional back school education is not surprising: traditional back school education programs conceptualized CBP in terms of an underlying structural problem and implied that the underlying structures are vulnerable to injury. A focus on a structural label for CBP may heighten the patient’s attention on pain, and emphasis on the vulnerability of the spine to damage has been shown to increase patients’ health care consumption (Hirsch & Liebert, 1998). The emphasis on a peripherally located source (disc, joint, muscle, nerve, etc.) taught in traditional back schools failed to include the neuroscience of the complex nociceptive and pain mechanisms, resulting in a “single source” (isomorphic) understanding of the relationship between the pain perception and the labeled, peripherally-located damaged tissue or source (Moseley, Nicholas, & Hodges, 2004). Moseley, Nicholas, and Hodges summarize the complexities (many contributors or ”polymorphic understanding”) of the chronic pain experience that has replaced the single source mechanism description of chronic pain. The single source or isomorphic understanding usually taught in back schools limits the education about pain to anatomy and neurophysiology (Moseley, Nicholas, & Hodges, 2004). The multiple source mechanisms or polymorphic understanding begins with the anatomy and neurophysiology of pain, and then expands to include an explanation of the many other mechanisms that are now known to potentially contribute to chronic pain including pain cognitions, self-perceived disability, and physical performance (Moseley, Nicholas, & Hodges). Table 1 in

The Complexities of the Chronic Back Pain section that follows lists the mechanisms that have been demonstrated to contribute to CBP and form the current polymorphic understanding of CBP (Wheeler, Stubbart, & Hicks, 2004). In summary, back schools have realized the perils of labeling an anatomical source and ignoring the behavioral components of chronic pain. Back schools continue to have the various disciplines address their respective component of the complex CBP experience through multidiscipline and multimodal curriculum (i.e., behavioral therapists do behavioral therapy, physical therapist provide exercise, etc.) (Jousset, et al., 2004; Shirado, et al., as cited in Heymans, et al., 2005). The traditional quantitative inquiry affects the clinical delivery of back schools into such a parts or component approach. If each discipline continues to educate participants in their respective component, that influences how research is conducted and the future study of CBP.

Examples in Research Since the first appearance of the phrase evidence-based medicine (EBM) in the medical literature in 1992 (Guyatt, et al.), the concept has become established in the medical research community (Guyatt, Cook, & Haynes, 2004). Evidence-based medicine is a medical movement based upon the application of the scientific method to medical practice. Guyatt, Cook, and Haynes (2004) summarized the development of the levels of evidence and categories of recommendations that are utilized in ranking different types of clinical evidence according to the strength of their freedom from the various biases in medical

research. The evidence is to be balanced by clinical expertise and the values of the patient in arriving at the best course of treatment (Guyatt, Cook, & Haynes). This section looks at EBM in general and a trend to over-weight randomized controlled studies (RCTs) relative to clinical expertise and patient values. Evidence-based medicine. EBM emphasizes the need for rigorous critical appraisals of the scientific literature to inform and guide medical decision making, placing strong weight on the design of the studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. While it is acknowledged by Chou (2005) that in back pain research â&#x20AC;&#x153;some research gaps and methodologic shortcomings persist,â&#x20AC;? he states that the richer evidence base that now exists has greatly improved the understanding of what does and does not work for low back pain. The earlier review (Heymans, et al., 2005) of the effectiveness of group approaches was the best available evidence. Chouâ&#x20AC;&#x2122;s (2005) hope that EBM would improve the understanding of what does and does not work with back schools falls short when the latest reviews (Chou, 2005; Heymans, et al., 2005) indicate that there is conflicting evidence on the effectiveness of back schools compared to other interventions, waiting list controls, and placebo. As earlier described, the variability in the outcomes and controls in back schools confounds the statistical application of the EBM quantitative form of inquiry leaving the clinician wondering if letting the patient sit in the waiting room is any more effective than their back school. Nonetheless, the literature reveals a widespread agreement that

adherence to evidence-based practice will hopefully improve low back pain patient outcomes and reduce arbitrary variations in care (Chou, 2005). This agreement is based on the quantitative premise that CBP can be generalized to predict for specific individuals who share the same CBP experience an optimal treatment choice. The latest understanding of the complexity of CBP calls to question whether the premise will hold up in future studies. There was a concern raised that the elimination of â&#x20AC;&#x153;multiple cointerventionsâ&#x20AC;? studies from review is not reflecting clinical reality (Delitto, 2005). Delitto notes that it is extremely unlikely that the effectiveness of multiple interventions can be measured by simply adding the effects of the same individual interventions together due to the complexity of the condition. Delitto also questions whether studies could ever capture the ongoing changing of interventions during subsequent clinic visits. The same question could be asked of group approaches but has not been asked in the literature reviewed: Can standardized group curriculums capture the ongoing changes of interventions in subsequent classes? The next section examines the assumptions of the researchersâ&#x20AC;&#x2122; ongoing search for RCTs that might be able to capture those ongoing changes. The search for additional randomized controlled trials. Many of the studies reviewed, including the reviews of the studies, either began or ended pondering the conflicting evidence for nearly every form of treatment (Bogduk, 2004; Chou, 2005; Heymans, et al., 2005; Maier-Riehle & Harter, 2001; Shirado, et al., as cited in Heymans, et al., 2005; Van Tulder, Koes,

& Bouter, 1997). The usual conclusion or call for further study involved wording along the lines of needing to improve the design, execution, and reporting of RCTs to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain (Van Tulder, Koes, & Bouter, 1997). Many introductions situated their study by suggesting that the lack of consistent findings may be related to the fact that studies have been performed on patients who have widely differing types of CBP, but who are statistically considered part of homogenous diagnostic group (Bogduk, 2004; Chou, 2005; Heymans, et al., 2005; Van Tulder, Koes, & Bouter, 1997). The solution offered is to further reduce these groups into smaller subgroups by subclassifying homogenous types of spine pain as needed (Delitto, Erhard, & Bowling, 1995; Fritz & George, 2000; Van Dillen, et al., 2003). This subgrouping is exemplified by Van Dillen, et al.’s study, in which they proposed the need for further subdividing the category of “mechanical low back pain.” Van Dillen, et al. proposed the following five categories of movement preferences and pain generating movements: 1) lumbar flexion; 2) lumbar extension; 3) lumbar rotation; 4) lumbar rotation with extension; and, 5) lumbar rotation with flexion. In this literature review no articles were found where this argument for further subgrouping was taken to its logical conclusion: deeper subclassification ultimately requires treating each patient as an individual with a unique pain experience, rendering specific prediction of groups of patients untenable. Interestingly, the literature does demonstrate a desire for individual treatment in that the patients themselves find they want to know exactly what is wrong or

broken (desire for predictability) and want to be treated as an individual with unique qualities and concerns (Verbeek, Sengers, Riemens, & Haafkens, 2004). Patients do not want to be treated like everyone else with chronic back pain.

Examples of Patient/Consumer Expectations One study that looked at patient expectations in back care treatment revealed a desire for a clear diagnosis of the cause of the pain, useful information and instructions, pain relief, and a physical examination (Verbeek, et al., 2004). Verbeek, et al.â&#x20AC;&#x2122;s study identified the following patient expectations: 1) there are more diagnostic tests that can be run; 2) there are other therapies; 3) they can be referred to specialists; and, 4) they want a sickness certification. Those same patients also expected confirmation from the healthcare provider that their pain was real and expected a confidence-based relationship with the provider that included understanding, listening, respect, and being included in the decisionmaking (Verbeek, et al.). A dilemma occurs when trying to meet the above listed expectations during the patientâ&#x20AC;&#x2122;s first visit. Primary care providers find themselves unable to meet the patientâ&#x20AC;&#x2122;s expectations. The primary care providers have pointed to time constraints coupled with the inadequacy of information they can give to patients about their problem because accurate diagnosis of back pain is rarely possible and the uncertain value of most common treatments as reasons for failing to meet patient expectations (Cherkin, et al., 1996; Heymans, et al., 2005). The clinical reality is an increasingly demanding consumer that wants a provider to know the precise source of their pain and for the provider who has difficulty identifying that 46

precise source of pain, to be able to articulate that stress, emotions and other less solid factors influence the pain (Verbeek, et al., 2004). One more complication is that the pain profoundly affects the patientâ&#x20AC;&#x2122;s whole experience and they want caregivers to consider that their spirituality and religion plays a role in their condition as well (Maugans & Wadland, 1991). This literature review found a conflicting split between calls for greater specificity and predictability on the one hand and the need for individuality and depth of understanding on the other hand. In the next section of this literature review an examination of the literature dealing with the complex nature of chronic pain, neuroscience, and the injustices in treating chronic pain suggests important possibilities for addressing these apparently conflicting demands made by patients with CBP. The complexities of chronic back pain. Early in the development of back schools the premise of predictability that the quantitative form of inquiry demands could be argued based on the assumption that CBP was primarily a result of mechanical strain (Lankhorst, et al. as cited in Heymans, et al., 2005). The previously described history of the evolution of back schools reflected the growing knowledge of the complexities of CBP up to Moseley, Nicholas, and Hodgesâ&#x20AC;&#x2122; polymorphic understanding of chronic pain (2004). Because the number of studies and disciplines studying CBP is very large, a single summary review will be cited to illustrate the complexity that the current knowledge. The new knowledge of the complexity increases difficulty of

prediction of what interventions might be effective for CBP. Table 1 is compiled from Wheeler, Stubbart, and Hicks (2004) and lists all the factors known to influence CBP. Even if accurate objectification were possible for all of the mechanisms listed in Table 1 at some given moment, due to the context sensitive nature of the perception of pain (Ecclesto & Crombez, 2005) the measurements would change in a different way for each individual during any ensuing intervention and thereby limit predictability for the group. A further discussion of the need for a new form of inquiry to address the implications of the context sensitive nature of the perception of pain follows in the methodology chapter of this dissertation.

Table 1 Evolutionary Mechanisms in Chronic Low Back Pain (based on information compiled from Wheeler, Stubbart, and Hicks, 2004) [Authorâ&#x20AC;&#x2122;s image]

Evolutionary Mechanisms in CBP Neurophysiological: Peripheral; Peripheral to central; and, Central sensitivity. Psychological: Behavioral; Cognitive-affective; and, Psychophysiological Premorbid factors: Depression, dysthymia; Predisposition to somatoform disorder; Psychoactive substance-abuse disorder; Personality disorder or traits; Anxiety disorders including panic disorder; Childhood sexual abuse; Cognitive process; Psychosis, delusional pain; Traumatic factors; Anxiety/panic; Fear Psychophysiological response: Loss of control; Abnormal dependence; Posttraumatic factors; Anxiety, panic; Depression; Posttraumatic stress disorder; Anger/hostility; Iatrogenic substance abuse; Somatoform pain disorder; Symptoms magnification; Increasing time since injury; Disability mind set. Physical, Medical and Surgical: Surgical history; physical trauma/deformity; complicating medical diseases/limitations. Social: Job dissatisfaction or conflict; Compensated unemployment as disincentive; Family or spousal dynamics; Perception of norm, i.e., family history; Legal influences; Financial security; Limited education or vocational potential; Age-related factors; and Environmental stressors.

Race and Diversity Challenges In addition to addressing the challenges of the complexity and context sensitivity of CBP, there are also silent blind spots in the research communityâ&#x20AC;&#x2122;s predominant mode of quantitative inquiry in the intervention for those with CBP. Montuori (2005) described how the reductionistic form in its effort to reduce knowledge of a subject to the simplest terms by isolating variables and removing exogenous factors creates these blind spots, â&#x20AC;&#x153;mutilates, and indeed obscures complexity.â&#x20AC;? Factors not included in selecting samples of subjects for quantitative studies, or factors considered irrelevant would statistically tend to ignore or exclude effects specific to individuals in the minority (Edwards, Fillingim, & Keefe, 2001). There are studies that indicated that race and diversity are social factors not listed in Table 1, but that both race and diversity have important implications in both the understanding and the education of people with chronic pain (Edwards, et al., 2001; Green, et al., 2003; Rollman, 2005). Edwards, Fillingim, and Keefe (2001) stated that there is an increasingly diverse cultural mix in the patient population and that race, ethnicity, and culture distinctions have generally been muted in the pain literature. A study investigating disparities in intervention for pain found a significant difference in the pain treatment that blacks and whites receive (Green, et al., 2003). In a selective literature review of pain experts, Green, et al. found racial and ethnic disparities in pain perception, assessment, and treatment in all settings (i.e., postoperative, emergency room) and across all types of pain (i.e., acute, cancer, chronic nonmalignant, and experimental). They suggest that the sources of pain disparities among racial and

ethnic minorities are complex, involving the patient (e.g., patient/health care provider communication, attitudes, perceptions of pain, and ability to pay for services), health care provider (e.g., decision making, knowledge of cultural differences in pain perception, and time spent in assessment), and health care system (e.g., access to pain medication, settings, and staffing levels) factors. Green, et al. (2003) concluded that racial and ethnic minorities tend to be undertreated for pain when compared to non-Hispanic whites. A review of studies published in the Journal of the American Medical Association, Lancet, and the New England Journal of Medicine indicate that the diversity variables of religion and spirituality have been ignored across all studies in the review (Weaver, Flannelly, Case, & Costa, 2004). Over a three-year period, from January 1998 through December 2000, less than 1% of the studies published measured some aspect of religion, spirituality, or both, and none of them were pain studies (Weaver, Flannelly, Case, & Costa, 2004). Edwards, Fillingim, and Keefe (2001) called for more studies on patient-level variables, pain perception, the role of economic and health support systems, linguistically sensitive measures, race and ethnic factors underlying clinical decision making, healthcare delivery, and multidisciplinary efforts to translate findings into effective and culturally relevant interventions. The experts that instruct in the back schools do not reflect the growing diversity of the patient population. In physical therapy alone, the providers that are often teaching back school are almost exclusively (87.5% in October 2005) European-Americans, with 2.4% being African American and 2.9%

Hispanic/Latino (American Physical Therapy Association, 2005). Language barriers further complicate the process and promise to become an even greater issue as the number of non-English speaking patients continues to grow (Edwards, Fillingim, & Keefe, 2001). Edwards, Fillingim, and Keefe state that a similar under-representation of minorities could be occurring in many basic science studies, where the methodology unknowingly creates restricted laboratory conditions in order to carefully isolate and control specific exogenous variables and ends up overlooking important race and diversity influences. These shortcomings of racial and diversity sensitivity are not intentional, but are paradigmatic blind spots of research and provider communities. Such oversights in sensitivity to important factors in CBP are no longer acceptable for matters as sensitive and important as ethnic or racial differences in behavior, and Rollman (2005) states that it is time to â&#x20AC;&#x153;raise the ethical barâ&#x20AC;? to address such important matters. Future research on CBP will need to more inclusively attend to the many unique influences of race, diversity and spirituality. The next section highlights two examples of studies that were sensitive to context dependent mechanisms in CBP.

Anticipating the Future The two studies selected offer contrasting applications of complex thinking that recognizes the balance between scientific rigor and creative imagination (Montuori, 2005) in dealing with and understanding CBP. Sobaszek,

et al.â&#x20AC;&#x2122;s study (2001) is a more macrocosmic application looking at back education and rehabilitation within an occupational setting and addressing a host of influencing systems with good result. Ă&#x2026;senlĂśf, Denison, and Lindberg (2005) bring a more microcosmic application in their study that tailored treatment interventions for two women having recurrent or persistent disabling musculoskeletal pain.

Lille Study Sobaszek, et al. (2001) performed a four-year study of a sanitary education and lumbar rehabilitation program for health care workers with chronic low back pain at the University Hospital of Lille for over four years. The methodology was a mix of quantitative (absenteeism, use of health care) and qualitative (progression of pain and disorder, social and professional impact) methods. The subjects included 108 healthcare workers with CBP of greater than six months duration who underwent an intensive five-day, all-day back education training session by a multi-disciplinary team. The researchers understood that the employees were constrained within their system at work and the researchers anticipated the need for the cooperation of management to provide resources and funding for a long-term investment in the back education process. The program targeted the problems specific to the professional activities that each individual health care worker had identified as contributing strain on their job. The employer committed resources to change workstations and to the improvements of ergonomic processes that were identified

as contributors to the identified strain. A process of learning to identify hazards, reporting them, seeking improvements and then reassessing after the changes were made continued throughout the entire period of more than four years. The initiation of a sustained systems process within an organization rather than a onetime intervention by an outside organization was unique to this study. The back education team was composed of a physiatrist, occupational physicians, physical and occupational therapists, a podiatrist, and a psychologist. The team did not work in the isolation of their respective departments, but had the full engagement of the human resources department and the purchasing power of the hospital for identified occupational equipment needs. The authors conclude that global (medical, psychological, technical, and social) management was responsible for producing lasting results that lasted more than four years later, with 70% of the participants continuing to apply the advice they received in their everyday life. Management experienced the additional financial returns of reduced sick leaves, regardless of their cause, which were markedly shorter after training, particularly leaves that extend beyond three weeks. Participants entered the study over a period of time, but at an average of four years after training, absenteeism for low back pain was reduced by a full onethird. Forty percent of the participants also reported increased job satisfaction. The communication and sharing of perspectives and coordination of interventions amongst the global team also proved valuable on a cost/efficiency ratio financially. At the time of publication of the study the organization was continuing to run the program in its fifth year and enjoying the improved

employee morale and cost savings to the organization. Sobaszek, et al.’s (2001) study was not included in the Heymans, et al.’s (2005) review because the study lacked a control group for statistical comparison, so for clinicians looking for new approaches and relying on the latest review, the filtering bias of the Heymans, et al.’s review dismissed this study because it lacked the inclusion criteria of their review. The Lille study was significant in that it expanded the responsibility of CBP to a broader system than the employee, initiating a sustainable “continuous process of education” for both the employees and the institution within which the employee’s CBP experience occurred. While Sobaszek, et al. (2001) demonstrated a back school process that addressed a more macrocosmic perspective of CBP while also attending to specific individual participant needs. Åsenlöf, Denison, and Lindberg (2005) narrowed the approach to a very focused or microcosmic perspective of addressing chronic pain education by seeking to understand the multiple specific needs of the participant and tailoring their learning according to those needs. Åsenlöf, Denison, and Lindberg’s level of specification of interventions differs from the traditional back school curriculums that have employed standardized curriculums.

Tailored Treatment In a study by Åsenlöf, Denison, and Lindberg (2005), physical therapists in primary health care provided an intervention for two people with recurrent or persistent pain. Rather than a team of disciplines, as in the Lille study, the setting

demanded that a single profession (physical therapy) bridge the disciplines (physical therapy and psychology). The primary clinical philosophy was to guide the participants toward resuming activities that were avoided and not performed at the start of the study. The activities were resumed through the patient’s acquisition of necessary physical, cognitive, and behavioral skills. The activities selected to form a “curriculum” of sorts in this study were unique because the activities were related to what the patients determined to be important and were frequently engaged activities that had created instances of back pain in the patient’s everyday life. Åsenlöf, Denison, and Lindberg (2005) stated they wanted the activities selected to have importance to the patient and be activities that would occur between sessions for opportunities to engage the newly learned behaviors for the activity. Åsenlöf, Denison, and Lindberg based their study on the following principles: 1) a theoretical perspective of behavior change derived from social cognitive theory (SCT) (Stone, 1998), which states that there is a mediator (human cognition) between stimulus and response, placing the individual in control over behavioral responses to stimuli; 2) empirical support for the relationship between psychological and psychosocial factors for the onset of and adjustment to chronic pain and pain related disability; 3) integration of cognitive behavioral therapy/behavioral therapy principles and physical and functional restoration programs; and, 4) the need of individually tailored pain management interventions aimed at systematically identified risk factors and motor behaviors. The therapists emphasized behavioral goal assessment and systematic individualization of the

treatment throughout the intervention using a seven-step process as summarized in Table 2.

Table 2 Phases and Components for Individually Tailored Intervention (based on information compiled from Åsenlöf, Denison, & Lindberg, 2005)[Author’s image] Step

Phase

Behavioral Goal Identification and Assessment

Self-monitoring

Individual Functional Behavioral Analysis

Basic Skills Acquisition

Applied Skills Acquisition

Generalization of Skills

Maintenance and Relapse Prevention

Components Pain history; physical; goal identification; goal ranking; self-reports of activity, satisfaction, self-efficacy, fear avoidance, readiness to adapt new behaviors and treatment expectations. Select initial goal; create a self-monitoring diary for prospective recording of behaviors. Introduce and discuss determinants of disability. Specify goals and immediate objectives. Introduce physical, psychological, and planning skills for initial goal. Perform exercises and record. Merge basic skills and shape adequate behaviors; Guide performance in contrived clinical settings; apply to everyday life situations and record. Apply to subsequent goals on priority list; extend functional behavioral analysis; acquire new skills and apply daily life, recording experiences. Introduce strategies of maintenance skills; Identify future risk situations and record strategies; conduct booster sessions that included rehearsal and problem solving.

The process in Table 2 was followed over a four- six-month period. The physical therapy sessions were weekly initially where the participant worked individually with a therapist in 45- to 60-minute sessions. The physical therapy 57

sessions were eventually scaled back to every second to third week. Data was collected daily three weeks prior to starting, daily during the intervention, and at 1-, 4-, 6- and 12-month follow ups. The participants were responsible for recording their experiences, analyzing their responses, and working with the therapist to develop new strategies based on their specific experience and cognitive responses. The extended engagement across a longer period of time compared to traditional back schools, coupled with cycles of action and reflection of everyday experiences with the therapist’s assistance was unique to this study. The two individuals obtained positive outcomes from the intervention with both reporting improved pain control and decreased disability and pain intensity. The study most importantly provides a new procedure of systematic tailoring of the treatments to behavioral goals and individual patient characteristics using the traditional tools of physical therapy and psychology as listed in Table 2. The study bridged physical therapy and psychology in two unique ways. First, the lead physical therapist had additional postgraduate education in behavioral medicine. Second, psychological supervision was provided by a psychologist, though Åsenlöf, Denison, and Lindberg (2005) reported that the psychologist was not available for the regular practice sessions and the authors did not specify the psychologist’s role in supervision. The study by Åsenlöf, Denison, and Lindberg (2005) sought regular, specific input through self-monitoring and journaling from the patient while operating from at least two different discipline perspectives (psychology and physical therapy). It is also interesting to note the effect the social situation in Sweden had on both requiring and allowing such an across-

disciplines approach. The authors reported that in Sweden’s public primary health care system clinical psychologists and multi-disciplinary teams are seldom available and that the providers would not have ready access to a full team, necessitating the development of the intervention in its format. In the study by Åsenlöf, Denison, and Lindberg, the underlying healthcare organization and social setting reshaped the researcher’s perspective to consider how to best incorporate the known influences of interventions across professions to create a new approach and new knowledge about treating CBP. A physical therapist used a behavioral medicine approach to affect motor behaviors, cognitions, and activity in patients during the complex course of a long-term treatment program for two individuals with CBP. The utilization of interventions from two professions by a single therapist introduced a new model of chronic pain education that transcends any single discipline and individually tailors treatment.

Summary The two studies (Åsenlöf, Denison, & Lindberg, 2005; Sobaszek, et al., 2001;) offered exciting new possibilities in both group and individual care for those with chronic back pain. The limited evidence supporting back schools and the known complexities of CBP suggest to the reviewer that a new approach to education needs to be developed for those with CBP. Based on this literature review, the reviewer would include two aspects to a new approach: 1) a group education that would develop a process of management of behaviors and cognition for the participant to utilize in everyday life; and, 2) the approach would address the specific wider systems that influence the participant’s unique 59

experience of CBP. This literature review supported the need for a new educational process that would require: 1) a method sensitive enough to deal with specific complexities of each participant’s CBP; 2) the participants working to discover what mechanisms influence their CBP through their self-reflection (cognitions, fears, expectancies, etc.) and introspection; and, 3) collaboration between participants and the provider to utilize the provider’s expertise in conjunction with the participants’ discoveries made through reflection to together develop individualized strategies from across multiple disciplines. The use of a qualitative approach may ask new questions about CBP previously left unanswered or unasked in this literature review. Returning to Chesterton’s paraphrased quote, “It isn’t that we can’t see the solution. It is that we can’t see the problem” (Chesterton, 1986), the “problem” may be in the type of questions that have been asked about CBP. The purpose of this study was to examine and describe in rich detail a prototype participatory back school model that introduced a new pedagogy of back school education that included the above listed changes. The prototype back school addressed the complexity, individuality and depth of influence CBP has on the individual participant. The participatory nature of the model also provided an opportunity to observe what new topics would be included in the curriculum the participants developed for themselves that had not been reported or emphasized before in the literature.

CHAPTER III: METHODOLOGY Situating the Question in a Research Paradigm: A Qualitative Approach Paradigms help humans understand phenomena in the human and social sciences (Creswell, 1994). As a basic set of beliefs, paradigms guide a researcherâ&#x20AC;&#x2122;s actions and represent the core of the researcherâ&#x20AC;&#x2122;s convictions regarding the nature of reality and of knowledge, how we come to know our world, and what we value knowing (Denzin & Lincoln, 2000). Paradigms are useful in that they create assumptions about: a) how science should be conducted [in my study, this means how both researchers and participants can come to better understand the experience of living with CBP]; b) the social world [the meaningmaking of such experience by society and how that meaning can be transformed], and c) what serves as legitimate science (Creswell, 1994). The assumptions and practices discussed in the following sections guided me in both theory and method throughout the study. Both quantitative and qualitative methods are useful; however, they each offer different types of knowledge (Patton, 2002). This researcher selected a method for the current study based on the nature of the research question itself: What is the experience of people with chronic back pain (CBP) who take part in a back school program that is based on a collaborative inquiry model? Lincoln and Guba (as cited in Denzin & Lincoln, 2000) state that qualitative research is structured by five major interpretive paradigms: 1) positivism, 2) postpositivism, 3) critical theory, 4) constructivism, and 5) the

participatory paradigm. Since elements of the last three of these paradigms were appropriate for my study, I discuss them in more detail below.

Critical Theory Critical theory focuses on how injustice and power relations affect people’s experiences and how we understanding our circumstances (Merriam, 2002). Examples of critical theory research are feminist, post-structural, and queer theory. Critical theory—as a change-oriented form of engagement—frankly acknowledges its framework as fundamentally and explicitly political (Patton, 2002). In the current study, critical theory may inform themes relating to issues of power imbalance in participatory back schools (for example, connected to culture, ethnic orientation, or economics).

Constructivism Constructivism is based on the premise that human reality is fundamentally different from natural, physical reality. Constructivism holds that people construct a version of reality based on or “made up” of and shaped by cultural and linguistic constructs (Patton, 2002). In this case study, I constructed a view of reality regarding CBP based on the multiple realities I saw my coresearchers construct. That is, my reconstruction of the experiences of those within the collaborative inquiry was constructivist in nature. Constructivism has five primary assumptions. The first is that “truth” is a matter of consensus among informed and sophisticated constructors, not of

correspondence with objective reality. The second is that “facts” have no meaning except within some value framework; hence there cannot be an “objective” assessment of any proposition. The third assumption is that “causes” and effects do not exist except by imputation. Fourth, phenomena can only be understood within the context in which they are studied. The final assumption is that data derived from constructivist inquiry have neither special status nor legitimization; they represent simply another construction to be taken into account in the move toward consensus (Guba & Lincoln as cited in Patton, 2002). I believe the subjectivity of this perspective is not a weakness or flaw within case study, but rather that it is the best way for acquiring the depth and breadth of the participants’ experiences of this prototype back school. In its extreme form, constructivism can preclude any agreed upon meaning or reality whatsoever (Fay, 1996). However, such an approach would not serve the methodology of my collaborative inquiry back school. Consequently, I believe the participatory paradigm serves the broadest perspective while including the functionality of constructivism that underlies the case study methodology.

The Participatory Paradigm A participatory paradigm is one in which the co-researchers (including the primary researcher) are all searching for understanding and meaning by engaging in various modes of learning in a subjective, immersed reflective process. According to Heron and Reason (1997), a participatory worldview does not attempt to create an overarching framework of a single reality (realism); it is an

orientation that acknowledges the fundamental limitations of articulating reality within any single paradigm (fallibilism). Heron and Reason (1997) place the participatory paradigm within how we come to understand what is real as a participative reality. A participative reality is considered to be the relationship of a subject (the knower) and the object (the known); it has a subjective-objective nature. The subjective experience of reality for the knower is known in the form the mind gives it through participation, but reality is also objective because the mind interpenetrates the reality it shapes (Heron, 1996). Thus co-researchers hold that reality can only be known through participation. Specifically, this reality is known through what is termed an extended epistemology. Knowers perceive subjective-objective reality through four ways of knowingâ&#x20AC;&#x201D;experiential, presentational, proposition, and practicalâ&#x20AC;&#x201D; (Heron & Reason, 1997), which are described in greater detail below. It is critical that all four subjective ways of knowing are sought and held in awareness, because each way of knowing informs the others. That is, if one form of knowing is lacking, this limits the other three ways of knowing. Traditional back schools typically involve primarily propositional knowing, with occasional forays into experiential knowing (through activity and demonstration); there is not an intentional integration of all four ways of knowing. The methodology of a participative paradigm is one of political participation (Heron & Reason, 1997). From initiating the inquiry questions, the agenda, and the actions to be undertaken by the group, the use and distribution of power is spread across all participants. The sharing of power allows for a

collaborative process of knowledge formation. In addition to the idea that reality is understood through the researcher’s four ways of knowing, those ways of knowing are always considered to be embedded in a language and culture of others as well. Consequently, what can come to be known of a participative reality is always arrived at in participation with others; Heron and Reason (1997) call this critical intersubjectivity. Ultimately, this points to what I believe is the problem under investigation. In contrast to traditional back schools, the participatory research approach of the back school in this study rejects the idea that one generalizable solution (a single back school curriculum) can fit multiple situations (Reason & Bradbury, 2001). Hence, the participatory back school is rooted in the participative paradigm and the bounded experience of my case study.

Characteristics of Qualitative Inquiry Qualitative research generally seeks to understand a subject from that subject’s perspective (etic), not the researcher’s perspective (emic) (Merriam, 1998). In my study I captured the participants’ experiences of the participatory back school, including my own as a co-researcher, rather than adopt the perspective of an outsider. Merriam states that qualitative inquiry is interested in understanding the meaning people have constructed as they make sense of their experiences and their world. This “why and how” orientation can generate multiple new perspectives on realities for the researcher, the participant, and the reader (Creswell, 1994).

In reviewing the characteristics of qualitative research presented by Denzin and Lincoln (2000), Meriam (2001), and Patton (2002), I realized that these characteristics could be helpful in developing new understandings about living with the complex and challenging problems associated with CBP. In qualitative inquiry, the researcher is the primary instrument; human beings—the researcher or co-researchers in the case of participative methods—are the primary instruments of the inquiry. This offers certain advantages over the use of nonhuman instruments. The qualitative researcher can be immediately responsive and adaptive to unique situations, able to record non-verbal data, clarify input, check with the respondents for accuracy of interpretation, and explore unanticipated responses (Merriam, 2001). For example, during one session in the current study, the group decided to discuss nutrition. However, someone observed that several individuals were disengaged. The discovery of the reason for that disengagement—thoughts about the absence of a member who had some expertise in nutrition—resulted in the group deciding to postpone the nutrition discussion in order to take advantage of the knowledge of the absent person in a later session. The complex nature of chronic pain cannot be measured by any single instrument. Pain has physical, emotional, social, and economic aspects, to name but a few. Because there is no “typical” day in living with chronic pain, a quantitative research model would not have been responsive to participants’ experiences of each moment. We would have been limited to measuring some “average” experience in an “average” day or week. The fact that qualitative inquiry utilizes the researcher, rather than another tool, as the primary research

instrument, was ideal for my topic (Creswell, 1994). As a qualitative inquirer, I was a responsive human instrument able to “discover” why a participant missed a class due to marital conflict, pending divorce, or physical relocation. This information would have been lost in a standardized, quantitative data collection form, or discarded as artifact, rather than yielding the kinds of valuable insights presented in Chapter IV. Who has more opportunities to intervene and to know what is contributing to the participant’s experience of CBP than that very individual? I contend that no one else does, and for that reason I directed my dissertation inquiry through a qualitative process. The quantitative approach would not have been sufficiently sensitive or flexible to allow me to discover participants’ experiences of my prototype back school. The decision to pursue a qualitative inquiry did not lock me, as the researcher, into a monolithic approach (Patton, 2002). In fact, I can appreciate why qualitative research has undergone significant growth and increased popularity in its relatively brief history (Reason & Bradbury, 2001). One characteristic of qualitative research is purposeful sampling. This researcher did not seek an average “case,” but purposefully looked to garner full and rich description of the lived experience. The participants were viewed as potentially offering illumination and “rich information” for the study, rather than as needing to “fit” into a preconceived category or having to serve as an empirical generalization of a sample population. The researcher sampled the contributions of participants that offered, “useful manifestations of the phenomenon of interest” (Patton, 2002, p. 40). Consequently, the sampling for my study did not seek an

“average” sufferer of chronic spine pain, and I was able to include a spectrum of experiences. Another characteristic of qualitative research is the use of the inductive process, which allows the researcher to “listen” to the questions and solutions of the participants, resulting in data from which to build concepts, hypotheses, and theories (Merriam, 2001). Allowing the questions to emerge from those living with the phenomenon of interest requires the researcher to shift from the position of “expert knower” to one of “inquisitive learner amongst a group of co-learners.” The inductive process makes possible a broad spectrum of results often not possible in quantitative research. Finally, qualitative inquiry is characterized by dynamic systems and holistic perspectives. The themes of dynamic systems and holistic perspectives as aspects of fieldwork and analysis strategies address complex social problems. The researcher, who was not attempting to isolate single variables, could focus on interdependencies and system dynamics not previously considered (Patton, 2002). The themes and patterns that emerged through the inductive process bridged various aspects of the social phenomenon, offering key insights that would have been lost in a less complex inquiry. These characteristics offered me as the researcher some essential concepts and strategies for inquiring into the topic at hand. My personal experience with chronic spine pain suggested the need for this flexible, inclusive process of investigating the problems associated with CBP, which are nested within the dynamic systems of modern society. Specifically, the participatory action research

form of qualitative research presented a process for exploring the situation with rather than on individuals with CBP.

Participatory Action Research (PAR) Case study—the particular method I am using—is a method commonly used in qualitative research. However, a case study using a participatory action approach—in which study participants themselves are viewed as co-researchers— is based on assumptions that are radically different from those adopted in traditional back schools. Given that the assumptions, processes, and structures involved in this study are not typical in the general practice of physical rehabilitation, I will describe them here in some depth. The physical rehabilitation professional is trained in objectifying or measuring results. Beyond those quantifiable values of strength, movement, speed, etc., there are the issues of quality. Why is a particular movement frightening? What is the meaning behind whether one can step down an eight-inch step? What is the value and how does this experience of this particular movement or function fit with the meaning of the rest of the individual’s life? As these questions emerged, and as the influences of multiple systems on a person’s behavior became apparent, the topics of “compliance,” “motivation,” and “adherence” came up. These terms in themselves reveal a reductionistic orientation and an unhelpful bias in much quantitative research on CBP. In contrast, a qualitative, participatory approach avoids this problem, because it focuses more on understanding (rather than pre-judging) the human experiences behind so-called “non-compliance.” 69

In summary, my back school was based on collaborative inquiry, which is a form of participatory action research, which in turn is a form of qualitative research. Just as qualitative research is a broad umbrella concept for a number of forms of inquiry, so too participatory action research (PAR) encompasses a number of forms of research including appreciative inquiry, action inquiry, critical inquiry, and collaborative inquiry (Reason & Bradbury, 2001). I will now identify some of the key features of PAR as they pertain to my back school model, laying the foundation for the next section about the paradigms that informed my research method.

Key Characteristics of Participatory Action Research Four Ways of Knowing In contrast to the traditional back school approach of an “expert” imparting knowledge to a “learner,” PAR acknowledges additional forms of knowing as being worthy of consideration. According to Heron and Reason (1997), participatory action research is grounded in four ways of knowing. Experiential knowing refers to the researcher’s direct encounter through participation—feeling and imaging the presence of some energy, entity, person, place, process, or thing. This includes the creative shaping of a world through the transaction of imaging it and perceptually enacting its forms of appearing. Presentational knowing is grounded in images from experiential knowing. Described as an intuitive grasp of the significance of one’s experience of the world, it is symbolized in graphic, plastic, and musical, vocal, and verbal art

forms. Metaphors and spatiotemporal forms of imagery are symbolized forms of experience with the world. Propositional knowing refers to conceptual terms that describe oneâ&#x20AC;&#x2122;s experience of reality through language of statements and various propositions based on presentational forms, and that are ultimately grounded in our experiential articulation of a world (Heron & Reason, 1997). Practical knowing involves demonstrating a skill or competency. The ability to act in purposive deeds based on the other three forms of knowing culminates in practical skills from action. Heron and Reason (1977) suggest that this practical knowing is a particularly important characteristic of participatory action research because it stimulates pursuit of knowledge that can be utilized for worthwhile human purposes for the group. Participatory research works towards practical outcomes and creating new forms of understanding, not purely theory production without action (Gustavsen, 2001). In the PBS, students sought to experience and develop practical actions that better addressed their daily challenges with CBP; if a session yielded no practical action, the group retained both the power and responsibility of eliminating or abbreviating that section of the session. Participatory action research is robust and flexible, and the research process is seen as a potential source of empowerment as well as a process for influencing professional policy and practice by reflecting the views and opinions of the service users, not just the traditional researcher (French, Reynolds, & Swain, 2001).

In the participatory approach, true understanding is necessarily informed by the three other ways of knowing; it is not simply a proposition of linguistic symbols ordered in a linear fashion. The essence of participatory practice as a whole involves critical subjectivity, which refers to the notion that the process of knowing results from ongoing interdependent feedback of the four ways of knowing. Critical subjectivity demands an awareness of how the four ways of knowing interact within a quantum relationship of continually changing relationships [dynamic systems] (Patton, 2002). For example, in the participatory back school (PBS), not only would pictures of anatomy be offered or described, but the group would also create opportunities to experience the anatomy, express their understanding, and demonstrate some practical action that arose out of the anatomical presentation.

Cycles of Reflection and Action The theme of cycles of reflection and action are another key characteristic of a participatory approach (Reason & Bradbury, 2001). The cycles build on the principles of critical subjectivity and the four ways of knowing. The circular and nonlinear nature of participatory research demands multiple perspectives. As the co-researchers (back school students) acted, they acquired experiences that informed presentational and propositional knowing; discovering this knowing in reflection led to other cycles of action (i.e., participation). The interweaving of these perspectives led to a depth of understanding, wholeness, and wisdom greater than words alone can convey. These cycles comprised the process by which the

ways of knowing were generated in the back school (as described in the example above about learning anatomy).

Active Participation and Personal Responsibility Additionally, participatory research as a holistic practice draws on the legacies of the exact sciences and so-called â&#x20AC;&#x153;softerâ&#x20AC;? sciences, rejecting neither, and including aspects of both. The participant is expected to participate, not to assume a passive role. Such agency and engagement leads to liberation from what too often in traditional back schools has become a passive, dependent relationship. Co-researchers also share in the design and control of the study (Reason & Bradbury, 2001). Researchers and co-researchers seek to utilize the post-conceptual mind, which can think about the very process of thinking and evaluate the assumptions supporting the experience of the phenomenon in question, as well as subsequent knowledge production based on that experience. These dimensions and characteristics pointed towards the particular design I decided upon. One additional aspect of PAR is that research validity rests in part on how it impacts the four ways of knowing and on whether the project results in an ongoing, emergent process of enduring consequence (Reason & Bradbury, 2001). In participatory research there is no final, absolute reality, only deeper inquiry into more questions and ways of knowing; this resonates with the attempt to understand the multidimensional complexity of CBP.

Selecting a Method: Case Study I used the case study method for this research project. Here I describe the steps involved in a case study as well as the strengths and limitations of this method. The case study provides an opportunity to carry out an in-depth inquiry into a particular individual, situation, or event (French, Reynolds, & Swain, 2001). Case studies present the actual descriptions of human experience that people have formulated for themselves. French, Reynolds, and Swain (2001) state, “The case study is an holistic research approach which can unravel the complexities of a situation” (p. 194). The authors further discuss the focus on real life events that happen naturally in case studies. Stake (1995) asserts that case study arose out of a need to study complex social phenomena. The capacity of the method for exploring experience and events was crucial in attempting to understand the experiences of someone living with CBP. The term case study has multiple meanings. It refers to a specific way of collecting, organizing, and analyzing data, and it also refers to the analytical process itself (Patton, 2002). The case study is a bounded system, limiting precisely what will be studied and how (Merriam, 2001). Case studies should not be confused with the clinical tool of case reports, which are more descriptive and usually dismissed as “not research” (French, Reynolds, & Swain, 2001). This is a critical distinction, because case studies examine not only the “what” of a particular bounded system, but also the very process of a detailed description. My case study consists of eight co-researchers (including me) who engaged in a 14-week inquiry that explored an eight-week participatory back school experience. There are three fundamental intentions underlying case study: 74

description, interpretation, and evaluation (Merriam, 1998). The aim of my study was to (a) describe what happened when people are in a participatory back school, (b) interpret their experiences, individually and collectively, and (c) describe the experiences they had in their everyday lives that may have affected their quality of life.

Limitations of Case Studies Case study research has limitations (Merriam, 1998). One is the potential for political bias due to funding of the study. This study received no outside funding. Another is the limit of time or money available to devote to such an undertaking. As a part of my clinical practice and having my own facility, I had time and sufficient resources to meet the demands of this study. A third limitation is that case studies tend to masquerade as the whole when they are but a slice of life. My strong background in quantitative research allowed me to remain sensitive to any generalizations I might have been tempted to make from this study. Further, most of my readers will share such a quantitative background, so there will be a minimal risk of generalizing to other groups or situations (Merriam, 2001). I encourage readers to consider their own situations and to examine whether or not it is possible for them to incorporate a participatory clinical setting in their practice. Another limitation of case studies is that they may oversimplify or exaggerate a situation, leading to erroneous conclusions. I used regular member check-ins, triangulation, and multiple data sources to bring balance to any

conclusions I reached from the study. Case studies are also limited by the sensitivity and integrity of the investigator. This concern is covered in detail in the section on ethical considerations of external validity. Selecting only the data that proves the points favored by the investigator is another potential limitation. I experienced this more as a freedom than as a limitation. I had no theory to support or hypothesis to prove. I can recall such a temptation in earlier quantitative studies. In this study, I believed that the process would generate supportive experiences for the participants, but acknowledged that I had no idea how that would be expressed individually. However, if no one had a supportive experience, that too would have been useful information to share with my peers.

Steps Involved in a Case Study There are three fundamental steps to constructing a case study: a) assembling the raw case data, b) constructing a case record, and c) writing a final case study narrative (Merriam, 1998). The raw data may include documents, interviews, recordings, and written text. The case record is a consolidation of the raw data that has been collected; it is organized, arranged, and edited into a coherent and workable form. The final narrative is a descriptive picture of the unit under study. My intention is to create a holistic and context-sensitive case study; ideally, the resulting narrative will take the reader fully into the experience of the participants (Patton, 2002).

My research strategy was to select a group of eight people (including myself) who were willing to experience a participatory back school. We participated as co-researchers in a 14-week inquiry of finding support for living with CBP. This 14-week inquiry is the case; it was a context-sensitive exploration that included significant periods of reflection and data collected from a variety of sources. The case study answered my research question–What is the experience of people with CBP who take part in a back school program that is based on a collaborative inquiry model?

Collaborative Inquiry in the Participatory Back School This section describes the processes of the event being studied: a participatory back school. Following that description will be the detail of my study depicting the relationship between the case study and the collaborative inquiry nature of the participatory back school. Collaborative inquiry was the most appropriate choice from among the various participatory action research strategies because, “With traditional research, complex issues are sometimes simplified or avoided because the methods are too rigid to accommodate them” (French, Reynolds, & Swain, 2001, p. 241). French, Reynolds, and Swain further state that strategies for participatory approaches should emphasize “those [methods] which are eclectic, inventive and flexible, giving room for new ideas to emerge and allowing for changes of plan and direction as the research proceeds” (p. 241). I believe collaborative inquiry fulfills these criteria.

A collaborative inquiry gathers people with similar concerns and interests to bring about creative action and/or revise their understanding of their world and transform their practice within it. Collaborative inquiry is based on the two participative principles: epistemic participation and political participation (Heron & Reason, 1997). A key discriminator of the experience of collaborative inquiry is that this strategy uses only the group members’ own experience (epistemic participation). Collaborative inquiry is transformative—in this case, transformations are related to personal well-being, processes, and the environment or skills involved in living with CBP (Heron & Reason, 2001). The data was the outcome of each member’s practical and experiential knowing; this has been informed and expressed through their presentational and propositional knowing of the epistemic participation. Politically, the facilitator did not create a detailed, specific design that the rest of the participants were expected to follow without early input. In the participatory back school process, rather than adopting a predetermined schedule and traditional curriculum, the co-researchers came together to generate the back school’s agenda. We utilized four phases of a systematic collaborative inquiry process of meaning-making identified in the University of Bath School of Management website, (Reason & Heron, 1999). Stage 1 is the first reflection phase, in which inquirers choose the focus or topic of the inquiry and the type of inquiry; a launching statement of the inquiry topic; a plan of action for the first action phase to explore some aspect of the inquiry topic; and a method of

recording experiences during the first action phase. Stage 2 is the first action phase, during which inquirers are exploring in experience and action some aspect of the inquiry topic; applying an integrated range of inquiry skills; and keeping records of the experiential data generated. Stage 3 involves full immersion in stage 2, with great openness to experience; the inquirers may break through new awareness, lose their way, and/or transcend the inquiry format. Stage 4 is the second reflection phase. The inquirers share data from the action phase and review and modify the inquiry topic in the light of making sense of data about the explored aspect of it; choose a plan for the second action phase to explore the same or a different aspect of the inquiry topic; and review the method of recording data used in the first action phase and amend it for use in the second. These four stages complete a full cycle from reflection to action to reflection; the number of cycles may vary. The relatively brief duration of this study moved through three full cycles.

Skills Required to Conduct Collaborative Inquiry Heron and Reason (2001) identify skills that must be developed to avoid having the collaborative inquiry process degenerate into uncritical subjectivity. The first skill is research cycling, which insures that the group moves through several cycles and avoids becoming mired in a single action or reflection. The second skill, relating to divergence and convergence, allows the group to maintain a balance of the natural ebb and flow between these two movements; this is important so that the group does not become either too focused or too divergent in

their inquiry so that practical action is lost. A third skill is authentic collaboration: intersubjective dialogue needs to be maintained to be truly collaborative, so no one dominates or is left out of the group. Fourth is the ability to challenge consensus collusion, i.e., making sure all members exercise their right and responsibility to challenge the group when they sense that collusion (absence of critical intersubjectivity) in any form is present. The fifth skill is the capacity to manage distress. Inquiry into a human condition such as chronic pain is apt to generate powerful emotional responses, including anger, fear, and anxiety. Such responses need to be managed and acknowledged appropriately to maintain the group. Sixth are reflection and action. Because groups tend to lose balance by engaging in either too much reflection or too much action, it is important to manage a balance of the two and to find ways to move the group forward out of too much of either one. Finally, group members must be skillful in preventing and managing chaos. The lack of a set reference agenda or curriculum in a democratic process is chaos. Knowing when and how to return order within the democratic process is a critical skill.

Selection of Participants As stated in the section on qualitative research, participants were selected in a way that provided for a full and rich description of the experience of CBP. In comparison to the restrictive sampling for most back schools, this study left the selection open to the broadest scope of participants possible in order to have access to the richest subject matter (Merriam, 2001; Patton, 2002). The eight participants of this studyâ&#x20AC;&#x201D;including me as both facilitator and participantâ&#x20AC;&#x201D;were 80

individuals who had experienced more than one year of persistent back pain. The context for the inquiry was an adult wellness education class. The sampling was of volunteers who matched the criterion of pain and were not in an acute flare-up nor under any treatment by a health professional beyond maintenance care. Volunteers met the following criteria: chronic spine pain of greater than one yearâ&#x20AC;&#x2122;s duration; clearance from attending physician; availability for the entire eight-week period; and willingness to actively participate in the actions between meetings. I recruited participants using a four-step process. First, I identified people who met the above criteria in the course of formal conversations that occurred in my personal and professional life. Because of an unexpected cross-country relocation, only one person was a former patient of my physical therapy and wellness practice. Next, I solicited physicians and other referral sources for appropriate candidates. Four came from peer referrals. Third, I posted a public invitation through print media and mailings to health clubs and studios. (Soliciting the public directly and requiring a physicians release is appropriate because the school is a form of adult fitness education and not prescribed physical therapy.) Two people responded and were qualified to participate. Finally, I sent a formal, written invitation asking selected individuals to participate. Many of the dozens of invitations and solicitations to support groups and individuals received no response.

The Data Sources of Data I relied on multiple data inputs in this study. During the first meeting as a partial participant in the group decisions, I presented to the group a list of potential choices to include as data for the study (Merriam, 2001; Patton, 2002; Stake, 1995). The group confirmed use of: Intake Interview Questionnaire (Appendix A); Dissertation Study Exit Interview (Appendix B); my research journal entries (not included as an appendix per Dr. Rachel Martin, methodology expert); Participant’s Journal Weeks 1-7, documenting actions and reflections— including initial pain narrative reflection (Appendix C); Participants’ Journal, Week 8 (Appendix D); Participants’ Journal—The Science of Personal Systems Inquiry (Appendix E); Roland/Morris Disability Questionnaire; Oswestry Low Back Pain Disability Questionnaire; Consent Form (Appendix F); Opening Night Checklist (Appendix G); Completed Narrative (Appendix H); Week 2 (Appendix I); Week 3 (Appendix J); Week 4 (Appendix K); Week 5 (Appendix L); Week 6 (Appendix M); and Week 7 (Appendix N). The group declined to use several forms of data that I suggested. Presentational knowing generated by the individuals was declined because coresearchers doubted they would be comfortable making a presentation. Input from outside the group, such as family members, etc., was declined because the group wanted to keep it as an experience only of the group itself. The recording of weekly group sessions (audio/video) was declined as too distracting for the facilitator and too inhibiting for the remainder of the group.

During the course of collaborative inquiry in the participatory back school, I collected the accepted forms of data, which structured the case study. I supplemented that data with member check-ins during class, requesting clarification or contextual background surrounding experiences of interest as necessary in post-class contact. The two questionnaires I employedâ&#x20AC;&#x201D;the Roland-Morris Disability questionnaire and Oswestry Low Back Pain Disability questionnaire (Roland & Fairbank, 2000)â&#x20AC;&#x201D;were included not as a mixed methodology or for statistical analysis per se; rather, I included these well accepted scales so that I could triangulate data collected elsewhere in the study for enhanced internal validity. Also, the use of these questionnaires is typically required in traditional rehabilitation periodicals that publish qualitative studies.

Data Collection Procedures The PBS was titled Active Back Support when presented to the community for recruitment purposes. The school was eight weeks long, meeting weekly for two hours. Following the initial organizational meeting that mirrored Heron and Reasonâ&#x20AC;&#x2122;s proposed agenda (2001, p. 186), the remainder of the agenda was designed to consist of cyclical periods of action and reflection. I served as a partial participator, acting as the facilitator and a co-researcher in the collaborative inquiry. The data collection was ongoing, including some preset and post-data collection, as well as collecting that data determined by the group to be of interest. I insured that the group maintained internal validity, reliability,

external validity, and a high ethical standard of practice through the specific procedures we used in data collection, data analysis, and presentation of the findings. The concept of a participatory back school contrasts in significant ways from the traditional back school curriculum. Here is a general outline of the process for those not familiar with collaborative inquiry. During the intake process prior to the group meeting, I met with each potential participant for an intake interview, collection of physician consent form, and completion of the Roland-Morris Disability questionnaire and Oswestry Low Back Pain Disability questionnaires (Resnik & Dobrzykowski, 2003; Roland & Fairbank, 2000). This process took between 45 and 60 minutes per participant. Session one was a full two-hour session that included introductions, orientation to process, and selection of the initial action cycle. Participants were encouraged to reflect and offer action items that they believed would support living with CBP. These action items could include topics presented in other venues that remained unclear, topics that they had heard of and wanted more information and experience using; some emerged in group discussion. As facilitator, at the end of the discussion I introduced other topics that were typically included. From that list of possibilities the group then selected the agenda for the first action cycle. The initial action was presented, practiced, and the guidelines for home practice/reflection were agreed upon and clarified. During sessions 2-7, the group continued with the cycles of action and reflection outlined earlier. During these cycles they made modifications to the

schedule as outlined in the Overview of Our Experience section of Chapter IV. During each class every person checked in with the group about his or her experiences and insights since the last session. There was a period of instruction or demonstration, followed by practice of those actions, reflection on that experience, and more group discussion and sharing as critical intersubjectivity. The sessions closed with clarification of responsibilities for home action/reflection and who would be responsible for the next sessionâ&#x20AC;&#x2122;s instructional/demonstration period. The closing session had a celebratory component during which coresearchers shared their discoveries from the inquiry. There was time for reflection on both critical and appreciative feedback, followed by a group sharing of that feedback. The session finished with a discussion of what, if any, continued action the co-researchers intended to pursue as a result of the course. This set an intention to maintain what was intended to be the start of a process, vs. a limited, healing intervention with an endpoint. In the outtake exit process during the week following our concluding class, I met for one hour with each participant. In this meeting we completed the exit interview, the exit Roland-Morris Disability questionnaire, and Oswestry Low Back Pain Disability questionnaire, and I answered any remaining questions. Five to six weeks after the completion of the school I completed questionnaires and fielded questions by phone.

Encountering and Analyzing the Data I intended to analyze data immediately following completion of the intake sessions. In fact, data collection and data analysis occurred simultaneously (Creswell, 1994; Patton, 2002). My initial analysis actually began informally during recruitment calls as participants shared their stories and questions prior to the formal intake interviews. These notes were captured in my research journal. As a collaborative inquiry, the group selected the specific kinds of data to be gathered during the first session (as noted above). After the first session, I sent the intake interviews, research log, participant journals, and SPSI to Dr. Rachel Martin (methods expert on my dissertation committee) on January 16, 2005, for review. Each week following the session I reviewed those sources of data.

Specific Analysis Procedures There are five strategies for data analysis: ethnographic, narrative, phenomenological, content analysis/analytic induction, and constant comparative (Merriam, 2001). In this study I used the constant comparative strategy. The tool of constant comparative analysis allows the researcher to note emerging patterns and meanings from the collected data. In addition to capturing a simple narrative description, I wanted to stay on the alert for categories of meaning and insights that might lead to theory development or support existing theory. Again, the emergent theme of qualitative research anticipates, but does not control, the product of analysis. For the researcher to take analysis to another level during the study is not unexpected (Merriam, 2001; Patton, 2002).

My approach to working with the data was informed by the insights and experiences of numerous authorities. I used an amalgamation of approaches, which I modified as necessary during the process. I utilized the procedures described by Creswell (1994), Stake (1995), Merriam (2001), and Patton (2002). In my reading of the data and observations of the sessions, I was open to insights and intuitions that occurred. As a co-researcher, I also shared these in the group as part of critical intersubjectivity; this sharing led to a profound learning for Nick, one of the group members and me that will be described in Chapter IV. I easily maintained awareness that I could not possibly understand or even describe all of the data. It was a comfort to recall that my purpose was to just understand the experiences within my case.

Analyzing the Data In analyzing the data, I did not stop at merely relating narrative descriptions of the participants and the group. Through my filter as the research instrument, I was able to not only observe and draw out the story, but also to “hear” the meaning of the story to the individual relating the story. The collaborative inquiry process was ideal for capturing the meanings in participants’ cycles of reflection on what was of value and how it contributed to their flourishing as human beings—core themes in some of our discussions. These indepth insights allow readers to glimpse the impact of the participatory back school on the lives of the co-researchers, against which they can reference their own or their patient’s experiences with traditional back schools. My intent is to present

the data analysis in such a way that the reader can experience the participatory back school on some level. It is not my intention to take the analysis deeper to the level of category construction or theory development.

Validity and Reliability I used the following recommended methods to establish validity, reliability, and ethics in my participatory back school case study. Validity and reliability in qualitative research are described as attending to the issues of trustworthiness, authenticity, politics, reflexivity, praxis, enhanced understanding, and the integrity and ethics of the co-researchers (Creswell, 1994; Heron & Reason, 2001; Merriam, 2001; Patton, 2002). Heron and Reason stated specific concerns about countering consensus collusion and managing distress; about monitoring authentic collaboration; and about balancing reflection and action; and managing chaos and disorder.

Internal Validity Given the participatory paradigm of this study, internal validity is concerned with how well our research findings match the reality (Merriam, 2001) of such a worldview. Since we were not attempting to identify an irreducible “truth,” the onus on the group was to convey clearly our experience of personal transformation during the study (Heron & Reason, 2001). We used a number of methods to insure that the co-researcher’s interpretation of data matched the constructed meanings of the participants’ (Merriam, 2001; Patton, 2002). Six methods were utilized: member checks, triangulation of data sources, repeated 88

observations, peer review, consensus collusion countering, and bracketing of researcher bias. Regarding member checks, as we undertook data analysis, I communicated back to the members feedback regarding my and possibly their interpretation of their experience. This actually occurred in every session as part of the reflection process rather than at sessions 3 and 6 as I had anticipated in my proposal. In order to triangulate data sources we used a number of sources of data including such traditional quantitative measures as triangulation points (as opposed to using a quantitative comparison paradigm). These functional and disability measures were for both the participants as practical action-related touchstones, and for future readers who will be largely unfamiliar with qualitative studies and used to seeing those types of measures. The triangulation data sources included repeated observations (made weekly by all participants); peer review (cohort member Roy Whitten and I have agreed to serve as peer review partners for our respective doctoral studiesâ&#x20AC;&#x201D;Dr. Whitten reviewed the material throughout the period of inquiry); consensus collusion countering (during each weekly meeting, I suggested brief periods of reflection on certain questions designed to ensure that each voice was being authentically and validly aired); and bracketing of researcher bias (in addition to bracketing my own biases, my bias as a partial participant maintaining balance between facilitator and co-researcher was monitored by the groupâ&#x20AC;&#x201D;surprisingly, we had no periods of emotional distress and weathered the chaos very well).

External Validity I now turn to the topic of external valididity. Asking how well the findings of a study can be applied to situations is a working definition of external validity (Creswell, 1994; Merriam, 2001). Because qualitative research specifies that it is not an objective to define a single predictive reality, early on such research was considered soft (Patton, 2002). Such an argument has paled, according to Patton, as the influence and impact of dynamic systems and chaos theories have been brought into the social sciences. These and other theories have exposed the inherent uncertainty and lack of absolute predictability in complex living systems found within the social sciences (Morin, 2005). In my experience, nothing better describes the experience of CBP than chaos theory. Unpredictable and multiple influences from a myriad of interacting systems (families, peers, community, nutrition, environmental, etc.) all influence every moment of the lived experience of CBP. Subsequently, the argument turns a full 180 degrees to ask: How can a relatively inflexible, hard science of quantitative study ever expect to offer a singular, predictive course of action in supporting those with CBP? The process of a collaborative inquiry then becomes the inquiry tool for an era of uncertainty. This inquiry involves not a specific, formulated procedure, but a process immersed in a lived experience that is comprised of multiple other system processes (Patton, 2002). Coinciding with Merriamâ&#x20AC;&#x2122;s (2001) suggestion to regard generalizations as working hypotheses rather than conclusions, this view suggests that the hypotheses should remain open to discovery within every collaborative inquiry.

Because each participatory back school will have its own unique mix of students, either diverse or relatively homogenous, it is their lived experiences—rather than their responses to some variable manipulation by the researcher (Heron & Reason, 2001)—that will generate conclusions. Hence, external validity emerged from our class out of our adherence to our internal validity (as discussed earlier). Further, Merriam (2001) regards the process of generalization as a method of maintaining external validity. Generalization is characterized by how well the study may be taken into the user’s or reader’s context or practice. This hallmark of qualitative research will be the true test of validity for my study. The collaborative inquiry method calls for such a radical paradigm shift from the traditional back school. The process of engaging in a collaborative inquiry paradoxically seems to be a method that calls only those with high social ethics to participate, yet because of it dependence on self-reflexivity, it remains vulnerable to abuse. When the internal validity measures mentioned previously are maintained, this paradox holds some of its own solutions. Unlike the distant, lone researcher secreted away in a laboratory, the collaborative inquiry facilitator not only is immersed within the community, but also openly calls upon the community to assist in maintaining the integrity of the study. In the current study, I addressed potential threats to internal validity (relative to researcher/co-researcher bias) not only by statements of affiliations on the consent form, but also by designing into and throughout the study itself ways for the entire group to address the issue. As the initiating researcher, I was self-disclosing and experienced emotional responses relating to

control, collusion, etc. However, I had built into the study design support for safeguarding breaches in ethics through regular check-ins with the rest of the group. Additionally, the relief of not having to prove a hypothesis to make the study a success removed some of the ethical temptations to stray from the integrity of the study. Steps I took to insure integrity included 1) using interview guides for all group and individual interview sessions; 2) adhering to the terms of the consent agreement; 3) personal self-reflection and self-disclosure to the group as part of the collaborative inquiry design (the group seemed to particularly enjoy that portion of each class!); 4) seeking group feedback as part of the process of managing emotional distress, group collusion, and issues of control/chaos/order (Heron & Reason, 2001); 5) allowing participants to contact me at any point during the study and afterwards; and 6) having participants give me written permission for all interviews and group sessions to be recorded in my journal and theirs with the opportunity to review afterward the transcriptions. Our findings were reviewed to be sure that each individual felt sufficiently protected. (We elected to express these findings in aggregate form, or, when referring to someone individually, to use pseudonyms to protect individual identities.)

Reliability Merriam (2001) stated that reliability within qualitative work should emphasize whether the conclusions are consistent with the data collected. In traditional back schools, reliability was concerned with whether the study could

be replicated by others (Creswell, 1994; Merriam, 2001). This is one of the key distinctions between a traditional predictive, back school grounded in a quantitative approach, with its expert instructor, and my participatory, qualitatively oriented back school, with its learner-participant facilitator. I do not seek to have my results replicated (do A, B, and C and get D); rather, I seek to demonstrate a process and a way of facilitating others in discovering meaning and flourishing fully within their experience of back pain. Reliability, then, rests on being faithful to the process of collaborative inquiry, rather than on the data collected or analysis performed. Since I had multiple rolesâ&#x20AC;&#x201D;as a partial participant, co-researcher, and facilitatorâ&#x20AC;&#x201D;there were certain issues that needed to be held in awareness throughout the process to insure that our findings would be consistent with the data we collected. These were transparency, peer review, and member checks. To insure transparency, I openly revealed all purposes, procedures, and results throughout the entire study. To get a more complete view of the process, I called on my academic peer and professional peers as well as on the other co-researchers to review the study on an ongoing basis. Member checks were made by all participants as part of their multiple roles inherent in a collaborative inquiry. The co-researchers were participants and owners of their individual experience, recorders of that experience, and also reviewers of not only the final transcription of their data, but also how that data was finally presented.

Limitations and Delimitations Limitations My purposeful sampling and small group size prohibits statistical generalizations to other groups. This afforded me unique opportunities for discovering the individuals’ experience of the PBS. The small sample size had the potential—if several participants had dropped out of the study before its completion—to negatively affect group dynamics. I tried to control for this asking participants to agree to full attendance; fortunately, everyone remained engaged throughout the process. The limitations of the study included the challenges of the collaborative inquiry process outlined earlier in this chapter, especially balanced participation and engagement by all members. I drew upon the suggestions offered by Heron (1997) to include inviting participation from quiet members, asking open-ended questions, and redirecting with new questions if a conversation was being monopolized by certain members. Due to the fact that we were conducting a collaborative inquiry and using democratic participation, the quantity and quality of data generated was variable and not controlled ahead of time by form or process beyond the home notebooks. While my study was a modification of a collaborative inquiry and had some basic inputs outlined, there was still the possibility of generating a wide range of depth and expression for interpretation, depending on the other decisions of the group. Also, I made no attempt to control participants’ efforts in the home actions and reflections assigned between sessions. I did address this by clarifying agreements at the end of each session and being available for questions between classes. Such support seemed to reduce the risk of participants not remembering or not 94

understanding what they were supposed to do, although there were some shortcomings. This study did not show whether the experience of the program persists or is modified over time. There was no long-term follow up to the 14-week program. This may be the focus of future studies undertaken to explore the experience of PBS beyond the actual school sessions. Another limitation of the design of my study was the fact that I played multiple roles. Acting as a researcher, facilitator, and participant put at risk my ability to get beyond my own perceptions of the group and subsequently the interpretation of the data generated. I controlled for this through triangulation, member review, and feedback on the data collected. It is my hope that the democratic strength of the inquiry will counterbalance this potential weakness.

Delimitations The Participatory Back School (PBS) was eight weeks in length. The study did not indicate whether this school would have been effective if the time period were longer or shorter period. The group met weekly; thus we did not gather evidence on whether the frequency of group interaction varied the participantâ&#x20AC;&#x2122;s experience. The participants had had back pain for over one yearâ&#x20AC;&#x2122;s duration. Therefore, the results of this study cannot necessarily be generalized to people with acute (very recent) or subacute back pain.

The group did have clearance from their attending physicians. Participants who were undergoing concomitant, non-invasive (massage, chiropractics, etc.) treatment of other types were not excluded from the study, since this reflects many peopleâ&#x20AC;&#x2122;s experience with CBP. The group was small in order to allow for depth and richness of description of the experience of the PBS. There were limits on diversity with regard to race, age, culture, mobility, and educational background because of the small sample. This limits the conclusions that can be drawn from the study with regard to people whose background or mobility levels differs significantly from the group engaged in the program.

CHAPTER IV: RESULTS

The results of the study are presented in three overall sections that are further broken down into more detailed sections. The Overview of Our PBS Experiences presents a brief description of the groupâ&#x20AC;&#x2122;s experience during the 12 weeks of the inquiry. Participants (which includes a separate subsection entitled The Group) is a narrative description of each co-researcherâ&#x20AC;&#x2122;s challenges with back pain, significant personal experiences during the PBS, future intentions for continuing the process, and any related lifestyle changes. In conclusion, Discoveries from Our Experiences explores our experiences of PBS, the answers to the research questions, and the themes that emerged during the collaborative inquiry.

Overview of Our PBS Experiences The PBS classes met on eight Monday nights from January 10 through February 28, 2005, and data collection continued through the exit interviews and final questionnaires in mid-April 2005. This section will highlight the significant events and curriculum of the program. Experiences of individuals and of the group as a whole will be discussed in detail in later sections.

Recruitment and Intake Interviews Recruiting participants was much more difficult than anticipated. Because I had recently moved to a new metropolitan area, I did not have very many past patients or referral sources; as a result, the start dates for the PBS was delayed. Up 97

until January 2, 2005, I still needed two more participants; at that time a colleague referred two ideal candidates who met the criteria for participation. The interview process went smoothly and participants were enthusiastic in sharing their histories and perspectives. There were very few questions about the collaborative inquiry process, and three of the participants stated they appreciated the opportunity to input topics into the curriculum.

Week 1 The first two-hour session was a very full session that included introductions, orientation to process, and initial action cycle. The full agenda for the first night is listed in Appendix G (Opening Night Checklist). The highlight was the development of the curriculum (listed below under Week 2). This process answered the subquestion of what topics the participants would choose that are not necessarily covered in traditional back schools. At the end of the discussion of possible topics for the curriculum, I offered additional topics from my experience, as noted next in Week 2. The group then selected what they wanted to cover over the 8 weeks and set the agenda for the first action cycle that night. They preferred that I assign the topics to various dates for the rest of the schedule because I was familiar with the time presentations for each; the group wanted to use its time that night for moving into the first action cycle. I presented the initial action on mindful movement and breath awareness; the group practiced, and the guidelines for home practice/reflection were agreed upon and clarified before finishing for the night. We also discussed and clarified

the completion of their personal narratives. An example of a completed narrative is located in the Completed Narrative (Appendix H).

Week 2 Following intake discussion, I presented and the group approved the following curriculum (based on earlier group input). Those topics not listed in the literature for traditional back school have an asterisk in front; the topics the I offered have a # sign: Week 2 Mind-Body connection * Increased flexibility . . . safely playing the edge Better Posture: pain alternatives (sit, stand)

Week 3 Emotions/stress and how they relate to back pain Pain: The role of strength, coordination, and stamina

Week 4 Strategies for sit/stand/sneezing and other ADLs Handling materials * # The ‘head to tail’ connection Week 5 Exercise concepts/modification of current exercises/nutrition’s role Sleeping/rest questions: a.m. mobility/ beds/chairs and car seats/inversion tables?

Week 6 Abdominals: Back care (pilates, yoga, sit-ups) * # Breathwork/sounding

Week 7 * Spirituality Natural ease of movement: How to achieve automatic “proper” movement 99

Week 8 Open . . . To Be Determined later. The discussion Anne initiated that night is worthy of special note. Anne asked about modifying the schedule for Valentine’s Day because that was one of the scheduled dates (Week 6). Significant discussion followed and it was determined that four of the participants would be either missing or inconvenienced by attending. We considered rescheduling to another night, trying an online meeting, or any other creative ideas. The group selected the online option with me collecting their experiences of the week 5, sharing that back to the group via email, and then providing additional materials be experienced on their own as a trial for an additional aspect of such a class when people have very busy schedules or miss an episode. They all seemed very enthusiastic about that adaptation; I asked if anyone objected and there were no objections. The group had seized its democratic power.

Week 3 The group had fun with the foot release exercise, discovering the unknown levels and asymmetries of tension and imbalance in their feet and how that affects their base of support. This small episode illustrated the power of a flexible agenda to yield new knowledge acquisition not set in the agenda. The episode began after the foot experience while I was answering a question of Rob’s. I suggested that in addition to the tension he had discovered in his jaws, he note what he could feel around his solar plexus. He paused, sensed, and was surprised I could “see” that 100

tension and asked me if I could “guess” areas of tightness in others (they hadn’t yet shared their discoveries). They were intrigued when my “guess” matched four of the six others’ discoveries. We noted that with practice, or with those we know well, it is possible to perceive tension or dis-ease that is not necessarily measurable, but that could contribute to pain patterns. They left prepared to discover even more layers of tension and imbalance within themselves and others they met.

Week 4 On check-in, Rob introduced what would be a central focus of study: compliance utilizing the discoveries of the students. This is a familiar dilemma in the chronic pain literature, and Rob’s experience illustrated what would be a struggle for the entire group. He had found valuable the discovery of tension in his jaw the week before, but didn’t follow up by returning to assess and release through the week, even though it had eased his back pain in class last week. He wasn’t even sure why, stating he wasn’t sure exactly what to do with that awareness. This was the first of what would be many conflicts between experience and future action around self-care.

Week 5 The group was progressing, developing a more intimate sense of sharing and camaraderie; topics discussed included how fast the class seemed to be going, participants’ struggles to get to class, alternative formats for delivering the class,

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etc.—this all reflected a thinking, reflective, self-organizing learning community in action.

Week 6 Valentines Day: Online week where I emailed the group as earlier agreed upon (Week 6, Appendix M) and later two follow up emails for support.

Week 7 Week 7 included the spirituality section, which covered how often our creed or story about who we are, what we are and how we are to act, is in direct opposition to our culture’s emphasis on harried, over-committed lifestyles (including volunteering for Back Schools!). We discussed again how our “stories” filter the stimulation we receive, which then sets system-wide tone, to include heart rate, blood pressure, muscle tension, pain perception, balance, etc. Participants were able to articulate these complex connections and shared several examples from their own experiences. Later, when some participants were asking questions about equipment, I stated there was little good evidence around inversion tables, and we discussed the mind-body principles or assumptions behind those tools. I suggested they ask deeper questions, such as what caused the tension/compression in the first place requiring the inversion, TNS, wonder widget, etc.? We had expanded on the theme of continuing to take our personal inquiry deeper than “I have pain . . . or a spasm” to why, and then again, why and so forth. This tied back to the earlier

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presentation on spirituality, directing our inquiry to get to the â&#x20AC;&#x153;spiritâ&#x20AC;? or source behind the imbalances we discovered.

Week 8 Everyone was there except Rob, who had been called out of town on business; however, he called to give his input and asked for email follow up to be sent to him. Check-in around the circle was rich, with honest sharing and personal disclosures. These disclosures provided many of the key insights and discoveries covered in the following sections. We then completed the original agenda, which included discussing follow up plans of interviews with a sign up sheet; 30 day follow up interviews to be scheduled when doing post-interview; questionnaires to be filled out now; the invitation for a complimentary after-care professional service for individual refinement of their program; and a reminder to rewrite narratives after discussion on same (sample narrative is available in the Completed Narrative (Appendix H). After answering questions about what happens to the data, confidentiality, and ultimate use, I told the group that I would seek their review on certain sections of the study. Following our closing practice together, we reaffirmed that the intent of our experience together was to be the start of a process, rather than a one-time healing intervention with an endpoint. I called the meeting to a close.

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Exit Interviews and Final Questionnaires The exit interviews and questionnaire completions went well. This data provided many of the poignant insights related in the remainder of this chapter. Without exception, participants were glad they had given their time, would recommend the program without hesitation, and were more optimistic about the future.

The Participants The seven co-researchers were assigned pseudonyms and have approved the text of their case studies, within which certain personal details were modified to protect their confidentiality while maintaining the integrity and accuracy of the description of their experience. There were two females and six males in the case. Details regarding age, occupation, and health history are provided in the summaries. The multiple sources of data were extremely valuable in constructing these individual summaries. The sources tracked changes in the co-researchersâ&#x20AC;&#x2122; perspectives over time in their personal narratives, and allowed me to compare their reflections, observations about them by their fellow co-researchers, and my own observations and reflections as facilitator. The sources added depth and dimension to the data. In all eight summaries, I have used quotation marks or block quotes to indicate the participantsâ&#x20AC;&#x2122; own words, whether verbal or written; the comments were taken either from their spoken word, my notes, or their journal entries. The reader will now meet the individuals in-depth and discover what they experienced in a PBS. As presented in Chapter III, this information is 104

qualitative in nature and not typically captured in the quantitative back school studies. This section partially answers the subquestion of what impact this program had on the quality of life and functional abilities of the participants. Following the individual introductions, the collective group experience will be documented.

Nick Nickâ&#x20AC;&#x2122;s Challenges: Nick is 51 and runs a successful high-end home entertainment business. He is under a great deal of pressures to get product delivered, stands for long periods of time on his feet in the sales area, and frequently has to move equipment that he knows he shouldnâ&#x20AC;&#x2122;t given his history of back pain. He had an earlier injury at age 18 lifting a piano but has had significant back problems for the past four-five years. He utilizes chiropractic support when necessary. He has a basic stretching program of five minutes that he does twice a day. His quality of life has been significantly affected in that he finds he is no longer able to drum in his band, which he enjoys, and he is limited to not being able to work out on a regular basis, which has affected his overall health and led to weight gain. Nick decided to participate in order to expand his knowledge of health issues; he had seen me for an interview/demonstration of mindfulness techniques beforehand and was intrigued by the results that he experienced. He has occasionally talked about his back problem with his wife, but beyond that has no other outlet to describe his experience. He is not particularly interested in looking

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at the emotional and spiritual effects on pain and has never had that addressed in the clinic. Nick’s Learnings in PBS: Nick was a very dedicated participant, taking thorough notes during class, writing detailed entries in his journal, and regularly engaging in his action cycles of home activities. He made many discoveries; the mechanical discoveries are shared here, and the more subtle, ethereal ones are described later. During Week 2 he noted how often he was thrusting forward vs. staying back on his feet and that this same habit carried over to his driving pattern. When he “set back” he noted the decreased tension and increased ease. During Week 3 he wrote, “The exercises brought me out of two bad days which otherwise would have laid me up for several days each.” He added, “One day I got up, had a lot of pain, laid back down and did breathing and the exercises helped!” . . . and . . . “During the week, I had a stiff neck and was able to take time to exercise with arms overhead and it helped!” Week 4 he shared in class, “Today, I again felt my lower back pop out of place and was able to reset it with my exercises.” In his journal he listed the two exercises that helped him the most from what we had worked on. Following the completion of the course he wrote, At the beginning of this class, a good day was just being able to stand up in the morning without pain or at least not severe pain. The tools that you have taught me have helped me to regain my confidence and I am able to do many of the things that I couldn’t to include breathing and stretching which has helped me get back on track. I am now going to the gym 3x/week. What I have noticed is that after I have exercised, my muscles gradually tighten up . . . before I can see how I would end up with a major setback after starting to exercise. Now I spend more time in the morning and at night stretching my legs back out and keeping my lower back relaxed, playing the edge really helps me work things out. I have noticed 106

the last two days that my concentration has also been getting better. I seem more focused. Breathing, stretching, awareness. In his exit interview Nick shared more about how these insights led him to modify his narrative around his pain. This is addressed in detail under Changes in Personal Narratives. Nickâ&#x20AC;&#x2122;s Future Intentions: Nick said that the program really clicked with where he is in life right now and is eager to continue to utilize those in his life. He has resumed playing drums with both his band and at Temple and intends to continue doing so, along with his three-times-weekly gym workouts.

Frank Frankâ&#x20AC;&#x2122;s Challenges: Frank, in his early 50s, is a member of a local police force involved in the development of the database and the collection of information in a sex-crimes area of investigation which requires short deadlines and some of the most intense, devious crimes. He is presently going through a period of significant change, leaving a marriage, moving a household, and maintaining a home environment for his children. He has had persistent back pain for 34 years in both the upper back and the base of the spine. During the past year and one-half, he has used a large amount of pain medication and also had to seek additional support for the intensity of his pain, interruption of his sleep, and lost work time. He is actively exploring various faith traditions and spiritual practices beyond his traditional family of origin practice of Orthodox Catholicism. He is intrigued by the nature of the care and is an active patient with me. He notes a definite relationship with stress, stating, â&#x20AC;&#x153;My low back pain increases and my 107

upper back begins to spasm under high stress.” He has had numerous disappointing encounters with health care givers who generally dispense medications and has been given exercise sheets in rehabilitation and told to perform their exercises under “supervision” with little personal intervention and no hands-on work. He has no one with whom he can discuss his pain. He states that the emotional and spiritual aspect of the pain has never been addressed and said, “I would have loved to have had that type of treatment. I have had major depression mostly due to the continual pain.” Frank’s Learnings in PBS: Frank took his learning to new depths through the school, using the tools to observe his pain and responses during the literal dissolution of his 20-year marriage and household. He wrote in his journal, While driving to work and sitting at my desk, I noticed that I was clenching my jaw. I would then relax the jaw with my tongue down and deepening my breathing. While doing this, I would then become aware of having sat too long in one position and practiced the shifting sand exercise. During Week 5 he was very happy with how quickly he recovered after moving and his willingness to rest rather than push through his pain. The following week he wrote, “Excitement about learning new breathing techniques. I am especially interested in how adding sound would help.” After Week 7 he recorded that he was very interested in the spirituality part of this work and “how that affects my body tension and the blood chemicals.” In his exit interview he shared, I am able to get around and able to move and no missed work because of this. Overall, I am more loose and comfortable with people with (my) elevated mood . . . I know stress is a huge factor and I need to be able to identify those situations even better. 108

Frank’s Future Intentions: Frank looks forward to reading more on the topic of spirituality and when seeking care in the future, he said, “I will look for a more hands-on person and am willing to consider the emotional and spiritual aspects of care.”

Anne Anne’s Challenges: Anne is a 52-year-old female health care practitioner who works with people with chronic disease on a daily basis in a busy outpatient setting. She has experience working in group situations and in one-on-one education and clinical care. She has had periodic episodes of back pain that over the years have created a pattern of fear and a tendency to avoid certain activities including recreational and social opportunities, such as kayaking, hiking, and camping. She values the benefits of a group process and states that she has no one with whom to regularly share her experiences about her condition. She is curious about the integrative nature of our clinic and how to gain flexibility, and she has a general intellectual curiosity. Anne appreciates mindfulness practice and hopes to create a direct relationship to both her self-care and exercises. She would like to develop skills to be more consistent in her program and avoid what she terms “postural crashes.” Anne’s Learnings in PBS: Anne was one of the most regular contributors in class discussion. Many of her learnings are shared later as part of the group discovery process. Another learning occurred for her when she led a group discussion on the purpose of class as being, not to “cure” but to “learn new self109

care for long term healing.” Later in Week 4 she journaled that she had found space for exercises by doing the exercises out of the shower, which was very helpful for comfort. Week 6 she wrote, “Still holding onto a feeling of centeredness and relaxation, sleeping pretty well.” During Week 7 she noted, Did breathing and other exercises, followed by mindful walk . . . it was great . . . like walking on air! . . . Great walks all week. Added breathing to exercises and regularly returning to the breath.

Anne’s Future Intentions: At the closing class she offered, “I am sort of sad . . . I am afraid it will be hard to maintain the practice.” She later would journal that she is, “Less fearful and the pain seems less mysterious.” She did make a follow up appointment for individual programming for hip pain, which seemed appropriate as she was the main proponent of the “tell me exactly how many and when to do what” charge described in the home exercise section. She also signed up at her faith community for a healing exploration class to continue her learning.

Rob Rob’s Challenges: Rob is a retired businessman in his late 50s with an active avocation that allows him to travel around the world. He has had 30 years of recurrent spine pain that restricts him from activities such as tennis and gardening. He is uncertain as to the source of his pain and has sought treatment around the country without significant lasting effect. In his travels he is forced to purchase three airline tickets so that he can lie across the seats, as he is unable to tolerate sitting; he does the same in theaters. He feels that people from whom he 110

has sought care in the past tended to be superficial thinkers who did not dig deeply enough to determine the cause of his pain. He is quite cynical about the back school operation; in fact, in one spine pain clinic he attended years ago, he literally crawled out of a window to escape the experience! He noted that stress has a definite role in both his back pain and stomach discomfort. He is able to share his experience with his wife on occasion, but has no other social support in that regard. He has utilized both a neurosurgeon and a psychiatrist in the past, but never explored the direct linking of his pain to emotional or spiritual effects. Rob’s Learnings in PBS: Rob was generous with his feedback, displaying both candor and directness in observations, as well offering constructive input on strengths and weaknesses of the PBS, as noted later in this chapter. Rob worked on his breathing and modified his sitting posture. One week he shared with the group a story about how he’d gotten through a meeting with a client using his breath awareness and modification. On his exit interview he noted that he had not made up his mind on the value of the work and wanted to learn more. He struggled with how to incorporate this new material into his dedicated ongoing regimen of exercises, and with the conflict between experiencing the effect and not repeating the action. He did journal that he was, “Looking deeper at what generates structural imbalance and needs to use non-local and subtle scans we learned earlier.” Rob’s Future Intentions: He would like to have one-on-one work done, but at the time of this writing has not followed up for his complimentary session.

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He is curious about how others in the group did, and he wants to read the study when it is completed.

Valerie Valerie’s Challenges: Valerie, in her mid-50s, is the administrator of a local charity program. She has suffered chronic spine pain for over 30 years as well as having other related chronic pain conditions her entire life. She is a serious student of pain management and has sought multiple avenues of treatment over the years. She has been active in support-group work for one of her related pain conditions and has sought alternative care in the Phoenix Valley as well as in California. She is applying for a master’s degree program that would allow her to expand her work and change to a different work setting. She utilizes several forms of pain medications on an as-needed basis and has a broad experience of chiropractic, osteopathic, and physical therapy services in the past. She agreed to participate because, “This may help me, and I always want to learn.” In the past she has found group work to be beneficial and is open to exploring any avenues of care. She presently has no local social support with which she can share her experiences of pain. She hopes to learn gentle exercises. Valerie’s Learnings in PBS: Valerie shared her group experience by willingly contributing to discussions and relating her experiences. Week 2 she reported a significant increase in cervical mobility while driving, noting she found that her neck moved more easily from side to side, with less pain in the neck area.

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Later in the course she noted the pain in her shoulder was less painful. Upon exiting her exercises had often helped greatly reduce her headaches. The following email exchange between classes illustrated an interesting learning for both of us:

----- Original Message ----At 04:58 PM 1/21/2005 -0700, Valerie wrote: Got it, Thanks. See you Monday. This session was really hard on my low back. Guess it has been so long, it doesn't know how to behave and stay where it is supposed to. Matt replied: Sent: Saturday, January 22, 2005 1:09 PM Subject: RE: Back School info from Matt Taylor I knew I should have insisted on getting you a pillow for your head, and belt to reach your legs so to get to the ends to meet your poor back suffered . . . a fine line between being directive and suggestive . . . I blew it . . . sorry. Have a great weekend, matt To which she replied: Hi Matt, We both learned. I should have recognized that it was too much. I have been dealing with the low back problems since 1991. I should know by now. See you Monday. V During Week 5 Valerie shared with the group her experience of the value of being patient and knowing “these things take time” bringing us back to process vs. “fix.” Later she journaled, “I learned more about my body and understand why my pelvic structure is so stiff.” She combined that learning with her earlier observation, “I’m more aware of my body; putting colors on parts of my body (gradients of pressure/tension like a weather map) made me more aware of it. Better understanding of my body.”

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Week 8 she noted confirming her earlier positive experience with groups, That other people have similar feelings to mine. I was able to express fears and the need for spirituality in my life. Physical gathering gives good feedback. I appreciate even more the emotional and spiritual effects on my pain. Valerie’s Future Intentions: Her future intentions were revealed in her journal: “We had accomplished a lot, yet I feel that I want more knowledge about techniques.” Also, she is “optimistic that there is more for me to learn to support myself with the pain.” She attempted to get approval for a PT prescription here but was not successful.

Eric Eric’s Challenges: Eric is an environmental engineer in his mid-50s who enjoys his work and puts in long hours. He frequently has to travel and carry heavy bags, then sits for extended periods of time in meetings. Initially he was not really sure whether he should participate, as he “just has back pain on occasion but it has lately [past two years] become more regular and intense.” He is participating primarily because of the interest of his spouse and the recommendation of a friend. He has a regular program of exercise that he does to try to maintain his flexibility. He has lots of questions about various other factors that affect his back and was wondering if there are things that he has missed. He would also like specific information on what to do when his back does hurt. He avoids activities that he used to enjoy, such as skiing and golf, and he notes a broadening cycle of lack of fun recreational activities because of his hesitancy. His prior therapy experiences include being passed around from physical therapist 114

to physical therapist, having to describe and explain his symptoms over and over again. He has no one with whom he can share his pain experience. He has never had spiritual or emotional aspects addressed in regards to his back pain. Eric’s Learnings in PBS: Eric began skeptical of his need to participate and became one of the most attentive students. At Week 3, with a sore back after tree trimming, he found relief when he, “Decided to run with first aid/care of back and also to revisit ‘the edge.’” Week 4 he had left upper quarter soreness, which he had discovered the class before that had since resolved along with his back pain from trimming, but was not aware the upper quarter pain was gone until I asked him. That same class he made a wonderful summary based on his ecological perspective in environmental sciences that our intention seemed to be to deepen awareness for ongoing development vs. “fixing” specific complaints; he wondered “are we really looking for a routine” or is this to develop 24/7 awareness and then change behavior based on that? Light bulbs clicked in the group and away we went with new understanding. Week 6 Eric came in to see me for an acute back flare-up and learned the McKenzie principles for acute lumbar postural shift with excellent symptom resolution and restoration of function. He later journaled, “Change in exercises has given me quicker pain relief.” Upon exit he noted, “I have gained confidence to try other activities and maintain better balance.” And that he’d learned, “much more than I thought I would gain.” He found his whole home program to be “very encouraging.”

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Eric’s Future Intentions: Eric journaled that he was “hopeful that I can continue to evolve my future in physical movement to prevent back spasms.” He did come in for his complimentary session of individual refinement and had resumed a long-abandoned daily sitting meditation practice as well.

Doug Doug’s Challenges: Doug, a physical therapist in his early 40s, works for a large rehabilitation corporation but is not satisfied with his work. He has a chronic arthritic condition that developed three years ago which limits his ability to participate in his favorite social activity of playing basketball. In the past he has worked as a physical therapist, but in the 1990s worked in an unrelated field for a time. He has since sold that business, returning to physical therapy several years ago. He has little familiarity with the principles of mindfulness and integrative medicine principles within physical therapy. He works regularly at his own health care by doing traditional stretching exercises and has noted some benefit by modifying his diet. He has no one to share his pain experiences with; while his pain level is at a relatively low level, it consistently interferes with his recreation. He has experienced multiple misdiagnoses by physicians, and he chose to participate in this study as both a professional collaborator and on the reference of a fellow colleague. He hopes to learn the principles of yoga and explore new ideas for self-care. Doug’s Learnings in PBS: Doug was the most quiet of the participants, holding back to learn and not being comfortable in groups. After the first class he

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noted how often he was lopsided sitting in the car and would now self-correct. Later in the course he journaled, “I realized I was tired of having to meet others needs and would like to have time for myself.” He also discovered that despite “being in the business,” he “didn’t realize how little time I spent in self-care.” Upon exiting the course he noted as most beneficial, “Attending to breath. Slowing down or trying to rest when symptoms flare.” He also shared how the course had made him look deeply at his dissatisfaction with his work environment and that he was beginning to explore possibilities for change. Doug’s Future Intentions: He journaled, “More optimistic because of multiple influences he can have on it (his pain).” Doug tried to schedule a follow up meeting to further discuss spirituality, but had to cancel due to work constraints. In a final conversation he said he intends to share his experience with others rather than keeping it so much to himself. [Note: in June he quit his job, bought a landscaping business, and states he has never been happier.]

Matt Matt’s Challenges: I was a 46-year-old physical therapist, a leader in integrative medicine principles within the physical rehabilitation field, having authored numerous articles; I taught the material for six years across the country and actively promote the progression of integrative medicine within physical rehabilitation. I was also an adviser to the International Association of Yoga Therapists and regularly contribute to their journal and organization. As a coparticipant in this process, I still had occasional episodes of minor back pain, but

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had not had a severe episode in four years. I practiced yoga regularly (though over the past year I did less aerobic exercise and experienced additional weight gain as a result. I recently had to move across the country and establish a new business, which disrupted and delayed the dissertation process, as I had counted on local patients to form the backbone of this study. I was also under financial distress as the new business was growing and during its first eight months it was not profitable. I entered this process somewhat frustrated and disappointed that it has taken this long, but also relieved to have it underway. I have taught groups before, but had some apprehension about whether this group will go “well,” as it is the focus of my dissertation. My hope is that it will be an important contribution to the health care field. Matt’s Learnings in PBS: My role as both participant and researcher allowed me a unique perspective and platform from which to share my discoveries during this study. The case was bounded by the Participatory Back School experience; the seven other seven participants ended by completing the final questionnaires. As facilitator and researcher, my experience of the PBS continues until the successful defense of my dissertation. It was during this extended window of observation and data analysis that I arrived at some of my most heartfelt conclusions. Consider first these journal entries of mine during the school: Week 1 Struggle to make these notes and importance of the discipline of doing it tonight there wasn’t an agenda for known form . . . the pressures of busier clinic, Week 2 Worn by possible litigious patient process . . . tired. Tired and empty. Did not do notes writing . . .

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Week 4 Fine despite limited attendance . . . much less tense and harried but not because I didn’t care . . . was out of my control Week 5 Employee concerns all day . . . Forced and tired . . . but I think put up an enthusiastic front . . . Once we started moving it went better; Still distracted with work environment . . . didn’t journal 2ndary to time commitments . . . .nor collect books. Week 8 Tired after teaching all weekend and very open to whatever would transpire tonight. After class: Spent and happy. We as providers complain about lack of compliance, failure to follow instruction and so forth, and yet even those of us as experts push, drive ourselves, and suffer along with our patients. What is it we are trying to prove or discover? It was on the Saturday morning I referred to at the close of the last section that I suddenly discovered and found a moment of insight into this entire process. This bit of “data” reflects the ability of the qualitative process to capture what never gets captured in quantitative data process of most back schools, while providing personal disclosure by the researcher. From an email on 9/5/05, Labor Day, to Dr. Elgelid, committee member and fellow physical therapist: Saturday as I was running my lit searches again, summarizing data themes, etc., I noticed my back was hurting and yet I charged on, squirming, curling, pressing forward as only we Germans can . . . and suddenly the whole study shifted and I had quite a moment of clarity about what I was ‘twisted up’ about: I was trying to put our experience into some previous box in the literature vs. using the lit to situate our experience. I went on in the email to relate impersonal and dispassionate the data reviews were for me. Once I realized that I had a methodology that allowed me to share the depth and personal insights of our experience, my back relaxed and the struggle receded in my review. I closed the email with this summary:

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Back pain is a process, not a part, and until we address the influences of all of the various systems we are merely trying to grab handfuls of the river of back pain with great futility. Matt’s Future Intentions: See the Discussion in Chapter V.

The Group Group’s Challenges: The group is well educated, highly motivated, volunteering for eight Monday nights, with several having to drive greater than 30 minutes to attend. They are here at no cost to them. They are all very busy with multiple commitments, ongoing education, and various family duties. Two members have some small group experience. None have ever shared their CBP in public. No one has experience with collaborative inquiry. Group’s Learnings in PBS: This section address the subquestion of how a local group of individuals came together as a learning community to support and teach one another practical knowing and understanding relevant to their individual context. The first night, Nick was ten minutes late and Rob 20 minutes late, but our first decision was to start without Rob and it was no problem for him when he arrived. There was the usual initial tension and Eric’s sarcasm, Doug sniffling with a very “fresh” cold, and at times it seemed Valerie “would never stop talking.” Later that evening the group warmed up and began to offer content such as a guided imagery by Valerie, jokes by Eric, and as a whole they did well on offering personal experiential feedback from exercises. During Week 2, when I

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asked if the sharing of experiences from the initial action in Week 1 the previous week had helped individuals to appreciate changes in themselves, they all agreed that it had. When I asked if it was it helpful to have my extra ideas in the agenda building, they all said “Yes,” but Anne made the excellent point that she found it interesting that what we did first was one of my contributions rather than one of theirs . . . got me! Everyone laughed and I admitted “guilt.” She followed by saying it didn’t matter, but just struck her as funny. The group demonstrated its democratic power the second week in their willingness to come up with home exercises in the e-mail and the online date modification. It was very creative (not something I had brought to the class), and they were very pleased with the outcome. During Week 2 Eric had noted that on the shifting sand exercise he had only one strategy to engage in, which was by lifting his feet; he wanted to know how else he might modify his movement. We used his question to demonstrate a review of awareness principles and linking movement with the breath, providing the group with an example of the power of the participatory process to drive the learning rather than adhering to a fixed curriculum. At Week 4 I discussed the value of their insights and the normalcy of the churning of frustration and confusion at that point. I also pointed out that we would be the first to capture this kind of experience and introduce it into the literature of the field, because most people don’t records the challenges to quantitative studies; rather, they just drop it as error or as not significant.

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That week we also observed how knowledge arose out of community when we demonstrated directed breath for increased awareness and function with Rob to enhance his compliance based on his “show me” request. Initially he couldn’t sit flat pre-action. We created his awareness of a stiff left hip with breath and hand perception, generating increased hip range of motion (ROM), and he was able to stand and sit normally in a chair the rest of the night without pain after the action . . . he was intrigued! As was group who then helped him develop awareness around addition tension habits they could sense/see (legs curled, back arched, arms/shoulders elevated . . . the students had become the teachers. During Week 5 we did our scheduled review of Previous Actions and Plan for the second half of the school, making adjustments per the group’s wishes. The group wanted the last session to focus on review and specificity of directions. There will be further observations on the group in the section entitled Benefits and Skills Acquired during PBS. Group’s Future Intentions: As a group, the co-researchers acknowledged the valuable contribution the group process generated. They also determined that their over-committed schedules, pressures from home and work, and various individual preferences made further work together untenable.

Discoveries from Our Experiences The Overview of Our Experience of PBS and The Participants created a context and frame of reference for the reader to appreciate the richness and variety of experience garnered in the case. This section will now answer in greater depth and with specificity the research question and its underlying subquestions. 122

The findings emerged as themes and patterns, providing answers to those questions and raising more for future consideration. Where appropriate I have bulleted or listed the findings to maintain ease of review.

Benefits and Skills Acquired during PBS This section will answer the questions of what practical skills participants gain in dealing with the complexities of back pain in a modern society during a participatory back school. An additional subquestion of this study was: What skills were derived in the benefits and how did they impact the participants’ quality of life and functional abilities? One or more participants of the PBS noted the benefits and skills described below. Benefits and skills that are described in greater detail later in this document are marked with an asterisk (*). The benefits were: •

Improved rest or sleep.

•

Decreased pain medication.

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Less anxious and tense in daily routines.

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Greater freedom of movement and activities.

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More regular exercise with greater confidence.

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Piqued curiosity to learn and read more about the course content.

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Dissolution of the “mysticism” around mind-body or integrative medicine.*

•

Increased sitting and standing comfort.

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Decreased fear of movement. 123

•

Return to hobbies and recreation not previously tolerated.

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Awareness of “pushing” themselves beyond comfort.*

•

Freedom to explore additional explanations and meanings.*

•

Empowered to speak up for self-care.*

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Appreciation for the benefits of group health education.*

One or more of the PBS participants learned the following skills: Those marked “(TBS)” indicate skills often taught at traditional back schools. •

Enhanced breath awareness and basic mindfulness training.

•

Ease of movement when synchronized with the breath.

•

Alternative ergonomic strategies to include sitting, standing, resting and handling materials. (TBS)

•

Stress management techniques (deep breathing, progressive relaxation, use of music, etc). (TBS)

•

How to inquiry beyond basic first-order causality of pain.*

•

Identifying physical embodiment of emotions or numbness (dysthymia).*

•

How questions of spiritual focus generate biochemical and physical realities, and how to reconsider those narratives.*

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Awareness of interconnection between non-local (jaw, tongue, feet, etc.) tension influences and can modify pain experience.

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Mindful walking.

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Nutrition as a spiritual consideration.

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The use of sounding and voice for relief of pain. 124

•

The use of mudras.

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The use of guided imagery for relaxation and pain relief. (TBS)

•

The use of directed breath (Prana Vidya) for enhanced awareness and pain relief.

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Sleeping strategies and return to sleep actions. (TBS)

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Discerning quality of care regarding chronic pain.*

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Mindful movement practice.

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How to effectively “play the edge” in learning to increase movement.

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Identify anatomy and physiology involved in spine pain. (TBS)

•

Numerous breathing exercises (pranayama) beyond diaphragmatic breathing.

In summary, the PBS list included the benefits and skills often reported in TBS, plus a host of additional skills. In addition, there were two important differences of a qualitative nature that occurred in the PBS. First, PBS taught a process of broader, deeper inquiry by the participant into what influences their CBP, rather than focusing only on techniques. Secondly, these skills and benefits occurred as a result of the curriculum this particular group designed to answer their own questions.

Improvements Reflected in Scales Summary Table 3 outlines the changes participants experienced according to a range of 0-10 (0=no pain; 10=worst pain) pain scale rating, and the behavioral/functional changes noted on their questionnaires between pre- and 125

final assessments. There was no scoring of the questionnaires, as they were not utilized for statistical analysis. There were improvements in function for all participants; only Rob and Anne related any regression in function.

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Table 3 Changes in Pain and Disability Experienced + 30 Days after a PBS (Author’s image)

Name

Pain

Oswestry

Roland Morris

Improved sitting 2 levels to sit as long as I like; sex life 1 level normal/no pain; and, social life one level to normal but increases. Pain intensity decreased one level painkillers give complete relief.

Improved by dropping I sleep less well (# 18).

Scale

Nick

4 to 1

Frank

7 to 6

Anne

2 to 3

Rob

7 to 10

Valerie 6 to 7

Social life improved to normal and no pain; sleep declined to sleep well with tablets. Declined one level in lifting and sex life.

Eric

1 to 1

Doug

2 to 2

Improved personal care, standing, and sleeping one level each. Improved from prevents heavy lifting from floor to “can lift heavy weights but it gives extra pain.” No change

Matt

1 to 1

No change (all top)

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Improved by dropping stay at home because of pain (# 1); painful all the time (# 13); and, more irritable because of pain (# 22). Improved by dropping holding on out of an easy chair (# 7) and no longer avoids heavy jobs around the house (# 21). Declined by adding (#22) irritable with people. Improved by dropping (#4) not doing jobs around the house; (# 9 & 10) dressing slowly & only stand short periods; (#14) turning in bed difficult; and, (#17 & 18) only walk short distances & sleep less well; No longer avoids heavy jobs (#21), but now sits more to care for her back (#20). Because of back strain during PBS, still avoiding bending and heavy lifting on 4/15/05 to allow for ligamentous healing until 4/30/05. Lies down more often for his back vs. because of his back. No change (no checks)

Changes in Personal Narratives Throughout the study the participants were asked about their experience of pain, its sources(s), what it meant to them, and their relationship with it. This was done during the intake interview, the narrative reflection of Week 1, the narrative reflection of Week 8, and the exit interview. The participants shared that they found this to be one of the most powerful, engaging and important aspects of the process for them in the PBS. Nested within this process of narrative are two components not typically addressed in physical rehabilitative medicine: emotional awareness and spiritual explication (who am I, what am I, and how should I be or act). These qualitative attributes underwent scrutiny and refinement, leading to some of the most gratifying discoveries and frustrating disappointments for the participants. The implications are further illuminated later in this chapter in Barriers to Action and in Chapter V. Nick: Like most of the participants, no one had ever addressed the emotional and spiritual influences on Nick’s back pain. In his opening narrative he wrote: “My pain is caused by a bad disc and lack of cartilage.” and “Sometimes I think this is a payback for not being the best person that I can be.” Immediately after the emotional awareness exercise Week 3 he journaled, Emotion exercise seemed a bit abstract and hard to relate to. I am unaware of what a big part stress plays with this. I am trying to pick up a point on my body where an emotion is hard to figure. When you mentioned the emotion of ‘numbness’ (absence of feelings), that hit a nerve and made me feel that the sorrow I felt from some of my life experiences that I have numbed myself to them. Perhaps that ignoring emotion has caused a change in my posture without my being aware of it?

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In his exit interview he shared that he now knew that his back pain began as his painful divorce and estrangement from his children occurred several years ago. He was grateful for coming to a more direct understanding of what was at first “abstract”; the emotional awareness changed his narrative around his pain and he is considering getting support to continue working with that. Eric: The guy who didn’t think he needed to participate wrote at the exit, However, not able to sense physical sites or sites of emotions. I felt as though I may be too numb to realize this. Found the spirituality portion interesting and hadn’t thought of a lot of those perspectives, though can’t say that I have personally experienced them. I am curious to learn more. I see pain by incidence or process vs. things I am always doing wrong/ecological. I understand how disc history is an incomplete science. Eric has resumed a daily sitting meditation practice since the end of the class that he had abandoned nearly 20 years ago. Valerie: Valerie began the program with an authoritative narrative of exactly what and how her pain was generated, which she shared at length with the group the first night, to the frustration of several members. Later she journaled, Emotions can increase pain. Spirituality is an area that hasn’t really been addressed at this time. More aware of my body; putting colors on parts of my body made me more aware of it. Very poignantly, on Week 8 she shared her new narrative with the group, a heartfelt searching and emptiness for a defined meaning and redefinition of purpose as a practical spiritual need. Gone was the “knower”; sharing was powerful and generated a stillness and space within the meeting that had not previously been experienced. Later she journaled, That other people have similar feelings to mine. I was able to express fears and the need for spirituality in my life. Physical gathering gives good feedback. 129

Frank: In the midst of a complete redefinition of his life, family and spiritual practice, this bull of a man, hardened daily by chasing sex offenders, offered this reflection on his progress at Week 4: I felt great about the exploration of my emotions. I had never paid attention to where the emotion was being held and how to impact those body parts. I felt sadness and grief when I held my hand over my chest and anxiety went over my stomach. Breathing into those areas helped & trying to establish a nighttime ritual of stretching, breathing, and relaxing before sleep. I lie quietly and press my lips on the inhale to ease tension in my face and jaw. Still laying alternated bringing my knees toward my chest to relieve low-back pressure. I then listen to yoga music and practice deep breathing and this has allowed me to fall asleep easier and use less sleeping medication. Able to get around and able to move and no missed work because of this. Overall, more loose and comfortable with people with (my) elevated mood. And in his final narrative: I see how my pain can be controlled and how stillness is a valuable part of healing. Much better control with my pain medications and awareness of how stress feeds into it both at work and at home. I don’t know exactly what causes it but I understand much more than just a bad joint and changing situations. A lot more optimistic about my ability to work through this pain and improve the quality of my life. Anne: Had a very deep narrative coming into the course, but had not been able to relate it or connect it to her “exercises.” Week 5 she journaled, “Very spiritual week and reflective . . . these techniques are a part of that process.” And on week 6, “Profound sense of well being from last class into the end of the past week. Fascinated with how mudras alters breath.” On her exit narrative she wrote, “Less fearful and the pain seems less mysterious. Understand the clinical history but now see far more influences on the “bad” part.” Doug: After Week 7 he wrote, “Curious about spirituality. Intrigued by the material and I have lots of questions. Enjoyed the class, the best so far.” Upon 130

exiting he said he really wasn’t sure how it fits with his life or why it (the arthritis) has happened to him. In July on a triangulation call I learned he had changed jobs and bought a business he enjoys. Rob: On the intake Rob was not sure and does not have a well-described story for why or for the purpose of his pain and hadn’t really thought about it before. He has been told many things and is not sure what to believe. On the exit interview he related that from my [Matt’s] mind-body perspective with chronic pain, he is convinced of the “story” but feels one is asking for “a huge leap of faith,” and it may be “psyche selling that is not all physical, such as what I went through Sarno, but balanced.” The group was made up of various faith traditions and levels of participation within the respective traditions. While religion was not discussed per se, there was discussion of self-care, compassion, and non-violence in treatment and habits. Genuine curiosity was aroused when the group began to search beneath the initial causes and explored the network of deeper, more far-reaching influences in their pain experiences.

Changes in Future Consumer Behaviors Six participants in this study said that the PBS increased their standards for what they will consider acceptable care for their back pain in the future; the other two said it reinforced their standards as consumers. I did not see this factor measured or mentioned in my review of the literature. I will let the participants speak for themselves:

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Eric: “I will be more discerning with M.D.s and physical therapists and what they should know. I won’t tolerate being passed from person to person or superficial care.” Nick: “Earlier encounters have been superficial on the surface and now I would demand a deeper and more integrative approach.” Doug: “Yes, definitely would want someone to look at my whole life situation vs. isolated incident.” Frank: “I will avoid doctors that just provide medications; PT’s which show any old exercise and do no hands-on work at all. I absolutely will look for more advice and less pills and PT. PT will have to be more mindful. I am willing to consider the emotional and spiritual aspects of care.” Anne: “You ruined us!” Valerie: “I won’t tolerate anything but one-on-one treatment and very discriminating on who can treat or touch me if they don’t have an integrative approach.”

Group Process Experience When I sat down to draft this section on group experience, I initially included it under Shortcomings, because, based on my own experience of intense group involvement, I believed that this group would be disappointed in the process. As I reviewed the data for all group-related observations, I was surprised at how few negative comments there were and how, in the final summations, there was a high regard for the value of the group. This positive regard for what by my standards seemed a “light” engagement, points to power of the community experience of knowledge development when the group is treated as something

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more than passive receptacles for information sharing. This will be a central theme in the discussion to follow. These are the discoveries and insights shared about the group experience from the participants themselves. Nick, Week 4: “Positive as a group; we are more relaxed and sharing our experiences openly.” In his exit interview he thought he learned a lot from what the group wasn’t saying, particularly about how people weren’t willing to look deeply at the various parts of their bodies that are out of balance, citing several participants by name. Frank: Week 1: Slight apprehension due to the concept of group study. “I don’t easily share personal details with people and tend to hold back in groups.” Then inWeek 5: “Definitely more comfortable with sharing and is (the group) coming around the idea of yoga therapy.” Upon exiting Frank shared: Agreed with much of what the group said and it was interesting how common our experiences were. [the group] Added focalization to my frustrations and needs to connect to the core of myself both physically and emotionally to identify imbalance; mindful awakening being more aware throughout the day of what I am thinking and feeling influences my physical health. Much better group than I thought and was very happy to see how we all ended up interacting. Rob: “Positive hearing other people not alone and how they benefited.” As the group concluded, he suggested that in the future, having group members read some material group participation would be helpful. He also thought that starting with icebreakers within the group and offering more simplified routines for each class would create structure to put people at ease. Eric: “Comfortable. Seemed level and greater familiarity with people and not a big part of the learning came from the group for him.”

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Doug: “Wasn’t bad for group work. Enjoyed group intervention and sharing of experiences. Seemed rather quiet but I’m more comfortable with that.” In addition to Rob’s comments, there were a few suggestions for enhancing the group process; these are listed below in the Skills Needed sections.

Required Participant Skills Identified during the PBS Skills Participants Need The following are the skills or types of awareness that participants and facilitators identified as needed to effectively participate in a PBS. Some were identified as having been present, while others were noted to be lacking either in themselves or in others within the group. This was in response to a specific exit interview question; these findings were based on both their own experience and observations they made of others in the group. This list supplements the findings by Heron and Reason (2001) in Chapter III of the skills required for a successful collaborative inquiry: an ability/willingness to disclose personal experience in a group setting; mindfulness of when you are dominating a conversation or topic; knowing and being comfortable in your role in the group; a willingness to share and demonstrate (presentational knowing) [such as when Rob demonstrated allfour’s sneezing technique, Eric a materials handling technique, and Nick his analogy to learning a new piece of music]; awareness of your own agendas and demands [such as when Frank wrote, “Some pressure to speak out since it seemed that the entire group was as quiet as I normally am and more reserved than I thought they would be”]; discipline to follow through on action cycles and

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especially engage in reflection periods; an open mind and not knowing all the answers; being flexible and willing to be patient through the process; and a willingness to look at your own thinking [as simple as when Anne wrote, “many intrusive thoughts with mindfulness walking . . . kept being distracted”].

Skills Facilitator Needs The following are skills that participants identified as important to facilitating the group. The skills listed were a mix of attributes they found in the facilitator of this PBS or thought were lacking during the process. They answered this question both immediately in their journals after the last class and again in the exit interview. The findings were: •

Personal experience in group processes rather than just giving a lecture or teaching an exercise class.

•

An ability/willingness to disclose personal experience in a group setting, especially discomfort or mistakes. The group mentioned when I shared my concerns, excitement or acknowledged my not knowing the answer.

•

Being comfortable with the unknown of the process, as I journaled, “afraid they wouldn’t be ‘impressed’ . . . there wasn’t an agenda for known form.”

•

Able to clear your day and be present. Facilitating a group process requires more focus than merely acting out a lesson plan.

•

Identify your emotional state and that of others and respond accordingly.

•

Manage conversational flow and draw out others. Valerie wished I had been better able to draw people out in conversation and engage in conversation.

•

Sufficient flexibility to change direction as needed, such as, “When the introduction of methodology seemed to be boring and I was tense, so I cut it short.”

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•

Comfortable with all personality types and identify the strengths in each. Rob offered that opportunity as the self-proclaimed cynic as he said tonight, and yet was very engaged in the artwork in the clinic, Jenny’s career and makes regular notes, as well as taking time to jot down his reflections.

•

A willingness to broach topics the group selected, but are new to the facilitator. Anne wrote, “Matt’s a little reticent to explore spirituality deeply, perhaps feels it’s so personal . . . I could have spent more time with the topic.”

•

High energy and enthusiasm . . . as Rob noted, “Increased speech patterns and more ‘fire in the belly.’ . . . “Don’t be dry like a Toastmaster, but more like Billy Graham.” These skills will add to the requirements of future PBS facilitators and

suggest a possible need for additional training for potential facilitators.

Practical Participant Tools and Business Considerations During the PBS the participants identified practical instructional tools and guidelines for home cycles of action and reflection. The group learning also identified as important the value of receiving individual personal instruction in addition to the general group presentation. Therefore, what follows are the discoveries around how PBS might be used as effective programming for consumers in the future from both for-profit and not-for-profit organizations.

Marketing The content material and the group process was new to this group of wellinformed, high-to-middle income people who had been consuming services for decades for their back pain. At the last class and in some of the exit interviews, observations were made about both the potential and the difficulty of marketing 136

such a program. Their observations and questions were full of practical marketing challenges for bringing this program to other audiences beyond a free research study. They said it is important to be able to succinctly state what the school could offer potential participants and their physicians and that the explanation needs to be in “safe” language that would not frighten conservative prospects. They questioned the most appropriate way to list course objectives and format when the group itself generates the curriculum. Would knowing the degree to which they were expected to share in creating the curriculum confuse or scare away prospective participants? The length of time commitment was considered a possible drawback; there was a suggestion that possibly a more condensed version with longer class periods would be a solution for people who are already overextended. There was a good discussion regarding possible pricing structures, insurance coverage, consumer promises or guarantees, and pre-selling through mini-workshops or demos. The possibility of a promo video/DVD with testimonials and demos was suggested to increase “buy-in” and decrease apprehension. The group even went so far as suggesting that once a prospect was attracted to the group, what type of screening process for suitability would be required and how would it be scheduled and funded. As a momentary “focus” group in the final class, the co-researchers concluded that this type of programming would have broad appeal to their demographic market across all levels of back pain sufferers.

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Consumer Biases Rob’s background may be in marketing, as he regularly offered valuable insights into the fact that no matter how good the material, future consumption would need to address our society’s consumption biases. One night he offered that descriptions of the physical changes experienced “needs more miracles and pizzazz,” like an infomercial with hype and excitement. As a pragmatist, he noted that the public, and even he himself, needs mechanical intervention with demonstrable and immediate effects. He believes our culture is attuned to immediate gratification and satisfaction of the “wow” factor. We saw evidence to this effect on the first night when he and Eric were obviously engaged by a toe-neck mobility demo used to illustrate the non-local systems effects involved in movement. Anne had also said the demo was helpful in reminding her how little we really understand, and that for people with chronic pain this offers legitimate hope that they have not yet reached a dead end. Rob also at one point wondered if, had there been a fee for the class, motivation levels would have been different. We discussed this matter and concluded with a consensus that it would indeed shift dynamics if participants had made an investment and or if the teacher made a livelihood through giving these classes. Nick said, given a strong tendency towards impatience in our culture, it might be helpful to propose straightforward questions and answers at the beginning, rather than having to work through the process of agenda and

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development the first night. That led to the group questioning the willingness within the culture to share within a group rather than be passive spectators in a group class. All of these observations asked more questions than they answered, but yielded important information for future PBS providers.

The Value of Receiving Individual Instruction/Experience Having gone through a variety of experiences, the group thought a mix of both group and some individual instruction would be most effective. Rob told the story of what he described as a dissatisfying “cookie cutter” experience while attending a Sarno group experience; he also felt lost about how to incorporate this new material into his ongoing program. He felt that at least a single one-on-one session would have helped to give him specific guidance. Several participants, including Anne and Eric, took me up on my offer for a complimentary session. Valerie thought one-on-one care would have supported the process and actively sought an opportunity for care, but was denied by her insurance carrier. Nick related that he had come to the class because of a pre-sell experience in which Matt explained the study and Nick learned immediately practical techniques and realized there was new material available that he had never been exposed to in the past. Frank was an ongoing patient and was “hungry” for more information beyond the clinical interventions. Eric felt that perhaps his bad episode of back pain during Week 6 had in fact presented him with an opportunity to learn more techniques. In turn, he felt that learning these techniques would encourage him to approach pain from a 139

preventative point of view, since he learned very specific biomechanical principles for his unique environment. The group’s general conclusion was that a hybrid of group and individual instruction should be further explored.

Educational Tools and Materials for Home Action and Reflection Two challenges for future back schools are the flexible format and the self-directed nature of the process. How can a provider offer educational materials to take home when the agenda is not set ahead of time and may change frequently during class? The group wanted, demanded, and received support materials, but the unique setting of a motivated researcher pleasing his volunteers and having the skills to produce such materials off-hours made that possible. Here is an excerpt of the learning by the group, followed by a list of discoveries the group made about the need for home materials. On the second night Nick had some questions about technique and had stopped doing one of them because he could not remember exactly how to do it. Rob stated he would have done them more had he had reminders and subsequently didn’t. Others nodded in agreement as well. We discussed the constraint of not having a fixed agenda and the group decided they wanted written directions available and directed me to provide them in the future, acknowledging their preference for resources over flexibility of the agenda. Rob also called the day of week 3 to ask that handouts be ready the night of class vs. after the fact. I did so and discussed again with the group about how to balance a fluid agenda against prepared handouts. We agreed there were compromises both ways, but this group wanted handouts to go and make notes on the night of class. They were fine with postponing or skipping sections, but wanted to leave with notes in hand. This initiated a long discussion re: specific directions or not, our work being a process vs. a mechanical fix (do “a” when “b” shows up), and how sharing questions about this lack of specific directions in the group brought forward other participants’ questions that never would have been addressed. Anne stated, “I forget to do my exercises . . . not sure how much of what . . . the directions don’t stick . . . wouldn’t more specific 140

directions be valuable?” That led to discussing the tension between levels of responsibility/dependency vs. Independent and many others chimed in . . . Nick saying, “Don’t tell me what to do or I won’t do it,” but then he admonished and instructed the others to dedicate daily time . . . still later he offered the analogy of a musician’s approach of chipping away at something large like a new piece of music, but every day a little bit, as a discipline . . . quite a turn from his initial more directive manner of “don’t tell me.” Anne then suggested possibly each member create their specific action plan; maybe have participants make a self-commitment target prior to leaving each week? The group was really struggling in this balance, but also “hearing” their own conflicting desires and realities and questioning the assumptions behind their initial preferences . . . I stayed back . . . great stuff . . . Nick instructing, Rob asking questions, Eric quiet. So, the lack of specific, prepared handouts served as a tool for the group to learn together and to deepen their levels of inquiry about assumptions around what exactly they “needed” to succeed. The group dynamic also allowed them to flex their political muscle and come to a consensus of requesting support not originally planned for by the facilitator. The group had several other insights and suggestions. One was that the context of mind-body science or integrative medicine be used to “frame” the program for participants; this would give them a kind of touchstone for what might be an unusual experience. Anne and Nick suggested that having participants read, before the program started, an outline of basic principles would be helpful. The immediacy and low cost of e-mail, the ability to offer Adobe PDF format handouts, and having sufficient tech support to generate materials was critical. Because very few ideas came up during the agenda building, issuing a list of possible topics and pre-voting or selecting during intake the process might be useful. Eric suggested that participants be given more guidance on journaling

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techniques—knowing exactly what is wanted in the journal could improve the quality of information gathered.

Online Educational Experience Online week was the group’s creative idea for addressing Valentine’s Day obligations. (See Week 6, Appendix M, for details). The final consensus was that working online has a number of drawbacks, including breaking the momentum of the group, losing a sense of connection and sharing, and not having the opportunity to get immediate feedback or clarification. None of the members had any experience in online education. Here are some comments on how they saw the experience.

Frank: “Found the exercises interesting. I was familiar with some of them from therapy. Still busy unpacking the house and moving details, so I didn’t stay as engaged as I would have liked to.” Anne: “I missed discussion and interaction, but appreciated the availability of the night.” Rob: “I thought it was a mistake not to meet on the 14th. Group seemed to lose momentum there and also broke the routine.” Eric: “Not tuned in. Postponed the exercises and then was incapacitated on Friday by back spasms. (I saw Matt on Friday afternoon to receive advice for treating the acute pain.) I have been gradually improving since.” Doug: “Worked on home program via the Internet and enjoyed not having to rush to class after a day of work.”

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The group determined that had they to do it over again, they would have gone with the original format of a face-to-face class.

The Influence of Other Systems on Compliance and Participation I noted in Chapter III that collaborative inquiry is a tool for an era of uncertainty and dynamic systems unpredictability. Collaborative inquiry is not a specific, formulated procedure, but rather a process of inquiry immersed in a lived experience that is comprised of multiple other systems processes (Patton, 2002). In our experience of PBS, we were continually surprised to discover that even with new knowledge and skills, backed by experiential knowing of the positive effects on our back pain, we often acted or behaved contrary to what we “knew” would help us. What were these barriers we encountered? Were they our “fault”? Were we really misinformed or unmotivated? Following are some thoughts from the group on what they believed influenced this well-educated, committed, and well-informed group of adults to not take care of themselves as they knew they should and could. These observations were garnered from participant journals, observations, follow up conversations, and group discussions: family demands on time (children, homework, school, cooking, cleaning, etc.); work deadlines (selfimposed and employer related); familial and cultural work ethic; community involvement (clubs, church/synagogue, service groups); 24/7 always connected via cell, email; Back School!; social obligations; travel (work and pleasure); commuting; information processing (paper, web, mail, books, etc.); recreation (hobbies, TV, internet, dining out, hiking, yard work, etc.); appointments (dentist, insurance, car repair, contractors, etc.); no time left . . . 143

Some comments indicate how we felt at various times: Anne, Week 8, “profoundly tired”; Doug: “Very tired from long day at work and just ran in without dinner. Glad it is the last class because of family pressures to be home. Eric, Week 5: “Hurried to make the class on time, feeling tired tonight.” Valerie, Week 1: “I’m excited to be learning new techniques, yet feeling ill, part of me wishing I could be home in my recliner with my pet,” and Week 3: “Like I really wanted to stay home and get into my new Jacuzzi, which was at optimum temperature.” And to sum us all up, Nick, Week 6: “Somewhat distracted due to long, busy schedule” and earlier, “Rushed and was thinking it would not be possible to attend this study.” In my journal I observed that my co-researchers’ comments offer a rich source for learning about compliance—their desire for specifics vs. railing against the many “have to’s,”, questioning the level of patient responsibility, and other struggles with compliance. These personal stories were so deep and meaningful in contrast to dry percentages of arbitrary compliance or non-compliance. Consider the following reflections as examples of that depth of insight. The very next week Frank journaled that against all the pressures he’d momentarily succeeded in his own private victory of self-care: During the week I was packing and preparing my home for sell/closing/move. I became aware when my low back would begin to fatigue. Instead of just powering through it, I would lay with my feet elevated on a sofa allowing my low back to sag outward. I would then breathe into the area. By doing this, I was able to continue work throughout the week while taking a minimum of pain pills. Hard keeping 144

to my bedtime relaxation practice. Still trying to make it a habit. I have a tendency to skipping it especially when on pain medications. Doug, the physical therapist and care giver, noted: “I didn’t realize how little time I spend in self-care . . . I know what to do, I’m disciplined in other areas of my life . . . why not care for me? Rob wondered about the lack of financial contribution vs. a freebie being related to non-compliance because in the past when he has paid for tennis lessons, he shows up, and tends to get more buy-in. And finally, Eric offered: “I still need to develop more patience in the discipline but can see this as an ongoing process rather than just something I automatically do.” These comments point to the influences of multiple system that were involved in the individual participant’s observed “failure to comply,” but my own journal entry perhaps sums up the depth and irony of the situation best: September 3, 2005, 0800 hrs: one of the acknowledged leaders and experts in integrative medicine in physical medicine squirms in his chair, back stiff, shifted, and pulling hard to the right, mousing through the electronics stacks for the fourth hour in a row on the first day of a three-day weekend while his family still sleeps . . . all in the pursuit of helping others not have back pain!

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CHAPTER V: DISCUSSION

The experience of people with CBP who participated in a back school program based on a collaborative inquiry model was profound and meaningful. My purpose in conducting this study was to examine and describe in rich detail this prototype participatory back school (PBS) model. In doing so, I have introduced a new pedagogy of back school education that addresses the complexity, individuality, and depth of influence CBP has on the individual participants. The participatory nature of the model provided an opportunity to demonstrate that topics not addressed in the literature would be included in the curriculum. The participants chose those topics to match their specific needs; several of these topics had not been reported or emphasized in the literature (i.e., breathwork, playing the edge, spirituality, personal narratives, and somatoemotional awareness). The PBS experience produced new skills and insights into the experience of living with CBP for the participants. The results point to a need for health care providers and researchers to embrace the complexity and deeply personal nature of CBP with new forms of inquiry and multiple new perspectives. A transdisciplinary approach to chronic pain will facilitate a new process of empowerment and support for those individuals with CBP. A transdisciplinary approach will retain the best of the traditional approaches but boldly expand into many new perspectives seeking deeper and more creative modes of inquiry.

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This discussion will begin by advocating a transdisciplinary approach for addressing how CBP knowledge is organized within our western culture. Such a broad stroke change will demand the reorganization of the reality of healthcare delivery systems and future research. That section will include a discussion of the ways that TBS models could be changed to more comprehensively reflect current knowledge on chronic pain. The discussion then summarizes our findings, discussing ways to improve the PBS and suggestions for future research. The discussion ends with a reflection on the larger systems relationships we discovered and how CBP is woven into the greater whole of our lives.

Towards a Transdisciplinary Approach The need for a wholesale change in how we organize our knowledge of CBP is not unique to physical medicine or healthcare as a larger system encompassing physical medicine. As the information age has revealed the complexity and interconnectedness of reality, every organization and institution of knowledge is realizing the need for such change (Montuori, 2005). Rothstein (2004) noted that physical therapists can take solace in knowing that they are not alone in seeking better ways to present and look at data and report the results of inquiries. The changes in inquiry I propose will require the construction of new realities within institutions, organizations, and healthcare delivery models. In Chapter II, the history of our present day â&#x20AC;&#x153;partsâ&#x20AC;? approach was summarized and the calls in the literature for the need for new approaches to address the complexities of CBP were outlined. In Chapter III, I developed the rationale for a participatory paradigm, specifically a collaborative inquiry 147

approach, as a new possibility of generating and organizing our knowledge of CBP. The findings reported in Chapter IV suggest both the promise and the challenges in validating the PBS and a transdisciplinary perspective. The stories of Nick, Valerie, Rob, Doug, Eric, Anne, Rob, and Matt provided a glimpse of how these people can now answer for themselves the “why” and the “how” to live a life of quality and fullness with their CBP. The challenge of bridging across the boundaries of the disciplines will be discussed before addressing specific changes in perspective that will be required in the adoption of a transdisciplinary approach.

The Challenge of Crossing the Boundaries In order to effectively cross boundaries between disciplines and revisit any body of knowledge, a new process of inquiry must be created (Montuori, 2005). There have been numerous multidisciplinary back schools in which participants moved from one specialist to the next, getting their muscles strong from professionals of one discipline, their stress relieved by another professional of a different discipline, and then learning to relax from yet another professional from another discipline. Those multiple forms of intervention are additive in nature but fail to transcend the various disciplines and their respective boundaries (2005). What professional intervening with the participant would be able to educate the participants in how it feels to simultaneously experience their tension, identify underlying fears/beliefs, alter movement, and be open to the re-assessment of the attempt of their last action? The complexity of CBP and the ability to address the

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more subtle issues—such as spirituality and forgiveness—demand a reorganization of the underlying knowledge of the multiple disciplines. The possibility of this type of reorganization of inquiry and practice requires what has been clearly articulated as “complex thought” by Edgar Morin (Morin, 2005). Complex thinking requires that the inquirer understand not only the content of information within the discipline, but also the assumptions or paradigms that guide the respective inquiry, as well as the inquirer’s own assumptions. Such a depth of understanding not only invites dialog and exchanges between disciplines, but also often creates new insights and perspectives that transcend a merely additive accumulation of the knowledge of “parts.” Montuori calls for a transdisciplinary form of inquiry that engages disciplinary knowledge and adds to it pertinent information from various other disciplines (2005). This plurality of perspectives on the same topic is not the traditional distant and impersonal objective quantitative approach; rather, these perspectives are coupled with regular interaction with the inquirer’s context and his or her lived experience, values, and beliefs (2005). Such a shift in the organization of knowledge has significant repercussions on how the topic of CBP should be explored by both professionals and patients. While futuristic in conception, the PBS method of inquiry utilized such a transdisciplinary perspective while operating from a participatory paradigm. Heron and Reason (1997) used the term post-conceptual mind as a key feature of their participatory paradigmatic approach. This new organization of what knowledge is and how inquiry is shaped and created was our PBS

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experience. While the PBS prototype offers a theoretical bridge amongst disciplines, only time and future publications will offer the evidence of whether the human drama of “turf-wars” permits such an application of knowledge in context vs. the dominant knowledge within disciplines. This section of the discussion now turns to specific changes in perspective that are needed for better care of CBP based on this study. I believe the following changes in perspective will yield improved care and understanding for those challenged with CBP.

Changes in Perspective It is important to understand that in calling for the adoption of new perspectives, I am not advocating the exclusion of the traditional forms of inquiry. On the contrary, by adopting new perspectives the traditional inquiries will be enhanced in the process. As in the Chesterton paraphrase mentioned earlier—“it isn’t that we can’t see the solution, but that we can’t see the problem”—my concern is that without changing our perspectives, we will not be able to arrive at better solutions for addressing CBP. It is important to remember that the current reconceptualization of CBP is that it is a disorder that evolves as a complex milieu, and that it is influenced by endogenous and exogenous factors creating a condition that alters the individual beyond the initiating pathologic dysfunction (Wheeler, Stubbart, & Hicks, 2004). With this in mind, I recommend the adoption of the perspectives outlined here in Table 4.

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Table 4 New Perspectives for Chronic Back Pain Inquiries (Author’s image) Traditional Back School

Characteristic

Predictive to direct healing interventions.

Expectations of Knowledge “Acquisition”

From experts and from outside the participants.

Sources of Knowledge for Self-Care

The individual’s; primarily physical and psychological.

Responsibility for/Source of Pain

Mechanical, Movement and Function.

Inquiry’s Emphasis

Inter or Multidisciplinary; additive. Within disciplines. Efficiency of delivery and endpoint oriented.

Paradigmatic Approaches Skill Sets for Providers Intention of Inquiry

Participatory Back School Uncertain, but open to further inquiry and creativity while generating improved outcomes. Plus from community participation and the participant’s inner experience. Plus multiple larger systems. Plus posture and movement’s intention and inspiration. Participatory and Transdisciplinary. Plus transdisciplinary. Development of life skills for the dynamics of individual and group processes.

Expectations of Knowledge “Acquisition” The TBS expectation of knowledge “acquisition” was that the back school and its instructor had the knowledge needed for caring for CBP and that the students attended the back school in order to acquire that knowledge. The complexity and increasing challenges of CBP caused Carey and Freburger (2005) to suggest prudence in the treatment of CBP, rather than what might be considered the hubris of presuming to know how to resolve CBP. I would add to that a call for humility in our expectations of being able to predict and ultimately control the experience of CBP. The predictive nature of the traditional

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quantitative approach has value, but the approach also has limitations. The PBS begins with a humble approach of acknowledging that while there is important information and skills to share with students based on predictive research, there are also factors that influence the student’s experience that neither the back school or the student have yet to discover. Furthermore, the PBS initiates the beginning of a learning process rather than presuming to provide an “acquired” predictable answer to immediately solve the problem. Only through listening to the students, their needs, and their ongoing discoveries, will the back school and student “acquire” new knowledge specific to that student’s unique back pain experience. This new perspective that knowledge acquisition about CBP is a creative process without certainty or absolute predictability will be a radical change in perspective for providers and consumers. This new perspective, however, would allow both providers and consumers creative options for possible adaptations and influences on the neuromatrix experience of pain. Together, in a humble spirit of uncertainty and curiosity, the researcher, clinician, and patient would integrate the patient’s values, the best research evidence, and clinical reasoning to deliver true evidenced-based medicine. If we adopt the perspective that knowledge does not exist “out there” to be dispensed with the certainty of pain relief, we are faced with the question of where we will find these elusive answers. Will our sources be the experts, the individual, or the back school?

Source of Knowledge for Self-Care The PBS model retains the importance of the experts and back schools as outside sources of knowledge for the individual. The important contribution the 152

PBS makes is the understanding that the knowledge for self-care is not simply the conceptual acquisition of information, but that knowledge for self-care is also generated out of the community experience of critical intersubjectivity. We found that there is unique, unplanned learning that occurs within the dynamics of an interactive group process where stories are shared and re-interpreted; this new understanding leads to new behavior. The PBS model also identified that the source of knowledge for self-care should not be construed as an either/or proposition of a one-on-one delivery model or a group process. We found that both individual and group processes were valuable in gaining new understanding and developing new behaviors. Working together, we discovered knowledge about Nick’s, Frank’s, and Valerie’s pain experiences that had emerged not from individual care but from their personal introspective work and the sharing of their findings with the group. Valerie’s shift from absolute certainty the first night to her poignant expression of realizing a spiritual void in her life the final night was a vivid example of the power of the group process to augment individual care.

Responsibility for/Source of the Pain One of the unintended results of the Western approach to knowledge is that as medicine has evolved, a tendency has developed to identify the pathology or brokenness responsible for the disorder as lying within the patient. I outlined in the literature review how this led to a focus on “parts” during inquiry. Unfortunately, this pattern implicitly suggests that the source of the pain is a defect within the individual that needs to be corrected. As we saw in the literature review, major areas of inquiry have utilized the classic mind-body split to explain 153

pain: there is either a physical or psychological pathology within the individual that is at the source of pain. In our case study, we determined that the sources of pain encompassed both physical and psychological aspects (as the traditional back schools focus on) and also very personal spiritual issues of meaning and purpose. We ascertained that the culture we live in, the technology we employ, the nature of our relationships, and the work that we do together weave a web of influence that shares responsibility for our compliance and opportunities to care for ourselves. As complex self-organizing living systems enmeshed in larger systems, our ability or even need to identify “the source” takes on less importance in CBP than the ability to continue to expand and deepen inquiry beyond old boundaries. The PBS model proved to be a powerful new perspective because it acknowledges the responsibility of both the individual and of the larger communities of the individual experiencing CBP. Such a shift in perspective and thinking about CBP will generate new emphases in future inquiries.

Paradigmatic Approaches The PBS model requires participants to take on a post-conceptual mind—a way of thinking about their thinking. By utilizing this critical reflective inquiry, we often found unexamined paradigms. In future back schools based on this model, researchers would inquire into their own paradigms; further, participants would be empowered to ask about the researchers’ and their own paradigms. An example of this in the current study was when Anne suggested that my selecting the topic of initial action and reflection was in fact reverting to the expert model! 154

This hallmark of the participatory paradigm within collaborative inquiry fits Montuori’s (2005) requirement for a transdisciplinary approach to be metaparadigmatic in nature. By embracing with passion creative opportunities and plurality of assumptions, future participants could explore their own motivations and fears to arrive at new knowledge. For those in the current study, our inquiry into our CBP truly did become “an opportunity for self-contextualizing, selfinquiry, and also self-creation” (Montuori, 2005). I believe one major paradigm change that was beneficial for us was when we looked at chronic pain as an opportunity for learning and creating rather than as a penalty or experience to be endured. Rockwood Lane (2005) relates how creativity and spirituality can heal by changing a person’s physiology and attitudes from one of distress to creative work. Olive (2004) noted that these changes in what I have defined as spiritual questions have largely been ignored in the research. When paradigms are changed or refined, the individual adopts new answers to who and what they are, and how they should act in the world. Handzo and Koenig (2004) believe that if care providers do not have an awareness of the person in all of his or her dimensions, they cannot effectively attend to and put in appropriate context the dimension for which they as providers have special responsibility. The PBS experience created an environment that allowed the participants to do just this sort of reframing of assumptions and creating of new possibilities for the future. Changing our paradigm changed how we organized our thinking about CBP, which according to Montuori (2005) creates new

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realities. One of these realities is that new skill sets will need to be developed by providers.

Skill Sets for Providers I see the need for new skill sets as potentially the most problematic change in the short term. The traditional back school, with its clean divisions of interdisciplinary boundaries, allowed for fairly consistent division of labor. The physical therapists and exercise physiologist took care of the movement, the occupational therapist helped put the movements to functional use, the psychologist addressed stress and mental health issues, and no one directly addressed spiritual issues by name (although the psychologists looked at beliefs and attitudes). Unfortunately, for example, there was no one to help a patient come to an integrated understanding of how her shallow breathing, which was associated with a sense of despair, could affect spinal loading in work simulation. Ă&#x2026;senlĂśf, Denison, and Lindbergâ&#x20AC;&#x2122;s study (2005) did offer a new model for some important first steps to beginning to bridge the professions of psychology and physical therapy. In the PBS we identified skill sets necessary for both providers and participants. The skills required both individual and group attributes, as well personal and interpersonal skills. In a PBS the facilitator must be able to modify programming on the spur of the moment and be comfortable in exploring emotional and spiritual concerns, while also attending to the needs of the group as a functioning whole. These are not skills typically taught in physical rehabilitation (with the exception of some occupational therapy programs). Rossignol (2004) 156

noted a shifting of attention from back schools, a patient-centered concept, to “going back to school” for primary health care providers involved with patients with low back pain. Rossignol (2004) stated the discovery that beyond social and cultural backgrounds, the variable effectiveness of guidelines for low back care could be a communication issue between health care professionals within and across professions. Therefore significant retraining and continuing education would need to be available, as well as the conviction of self-development on the provider’s part to address noted demands on personal levels of awareness we found in our study. Edwards, et al. (2004) proposed adopting what they call dialectical reasoning and transformatory learning as key portions of such future clinical reasoning skills. Edwards, et al. (2004) outline nicely how such bridging activity can fit into accepted physical therapy practice directives. Åsenlöf, Denison, and Lindberg (2005) also discussed how their tailored intervention would require significant continuing education for providers. More formidable than training needs however, is the question of turf wars over when does a PT prescribing breathing exercises for stress begin to practice psychotherapy or when does a psychotherapist utilizing tactile cuing for tension awareness start practicing physical therapy? Resolving the issue of bridging these now interrelated disciplines points to the institutional restructuring of practice realities and laws pointed to by Montuori (2005). In our study I, as a yoga therapist in a wellness education class, provided the service. The individual physical therapy sessions were only possible because Arizona is a direct access state not requiring a prescription and the service was complimentary, so there also

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was no need for reimbursement requiring a prescription. In many states without the yoga teacher designation this program would have required significant oversight from a physician. That restriction on practice is just one example that supports a need to open dialog between the disciplines with the care of the patients’ needs as foremost in importance. Such a dialog has been initiated with a second annual conference being organized in part by the author for 2006. Part of that dialog will address our collective intentions of care and inquiry. Given the current understanding of the complexity of CBP the patients’ needs must be the priority.

Intention and Emphasis of Inquiry The literature review described how traditional back schools evolved in part from a search for efficiencies of delivery of information to patients or at-risk groups about back safety biomechanics. In my clinical experience I have also seen a pattern by third party payers to use back schools as an endpoint in care. Once the patient with CBP completed the back school, the “system” would assert that “everything possible had been done” and either cut or limit future consumption of resources for that complaint. Whether the intention was efficiency, “cure,” or termination of care, a different intention on the part of back schools would better serve its clients. The PBS model takes on a more optimistic and empowering intention. That intention was to renew and revitalize the individual’s search for meaning, relief, and future new behaviors of self-care. The PBS reframed CBP as a process and then provided new processes of inquiry into modifying CBP by the 158

participants. We as participants left with new consumer preferences for future care and the intention to explore new options of self-care. It was my experience that this also removed the pressure on me as facilitator/provider to have all the “answers,” which in turn reduced the tension in my back. A shift of intention from prediction to process enhancement would allow all inquirers (researchers, providers, and patients) an intention that acknowledges and allows for the complexities of CBP. Our group requested and found useful the adoption of new perspectives in addition to the traditional mechanical approach emphasized in TBSs. Our PBS experience was that if we continued to ask “Why?” beyond the initial levels of our experience, we found questions of intention, inspiration, and meaning. Each of us had our unique frames of reference and life experiences, but our interaction together offered support and insight into our respective individual circumstances. From Nick’s initial question about whether his pain was the penalty for not living properly to Valerie’s initial certainty of what was causing her pain, we saw each participant gain new narratives of explanation and meaning around their pain. While these discoveries did not necessarily remove the pain, the individuals experienced hope and resolution to continue to inquire and explore rather than abandon hope or remain in despair as “graduates” of a back school that failed them. These changes in emphases mirror the new paradigms that would need to be adopted by future back schools.

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Suggestions for Further Research Prior to discussing suggestions for further research, a final reflection is in order on how this study could be improved if repeated. Following those suggestions for improvement, specific areas for further inquiry will be described and some final research questions will be presented.

Proposed Improvements for Follow up on this Study In Chapter IV the participants candidly shared their insightful suggestions for how the PBS could be improved in the future. Most of these changes were straightforward and require no further discussion, including: a) managing conversational flow and drawing out participation from all participants; b) facilitator confidence in presenting new material; c) high energy and enthusiasm in presentation style of the facilitator; d) better promotional material; e) better orientation information for participants before starting; f) better directions on journaling reflections and narratives; g) adding an individual instruction component; h) better home action instruction materials; i) not having a break in the regular meeting schedule; and, j) not having an online class. These improvements can easily be attained with either more training of the facilitator or improved administrative/organizational preparation. The participants as a group concluded that the area they were most interested in improving or discovering more answers was in the area of compliance. In our experience of the PBS we were continually surprised to discover that even with new knowledge and skills, backed by experiential knowing of the positive effects of these new actions on our back pain, we often 160

acted or behaved contrary to what we knew would help us. What were these barriers we encountered, were they our fault, and were we really misinformed or unmotivated? These questions around compliance were a central and primary theme that emerged from the data, and therefore deserves further investigation and discussion for future improvements of the PBS.

Improving Compliance in a PBS Repeatedly we inquired and discussed why we as individuals would not do what we knew and had experienced as effective in easing our back pain. In the literature this concern is defined as â&#x20AC;&#x153;compliance.â&#x20AC;? This section of the discussion will look at the definitions of compliance, background information on compliance, evidence for improving compliance or causing non-compliance, and past discussions of motivational and compliance improvements for future research.

Definitions and Background Compliance in health care often refers to the patient submitting to the wishes and instructions of the professional (Ryan, 1994). In contrast, noncompliance is when a patient's behavior does not coincide with medical or health advice (Cameron, 1996). Noncompliance can be intentional, if the patient exhibits a conscious choice not to follow the advice or instruction, or it might be unintentional due to poor comprehension of the disease or condition (Paddison, 2002). Noncompliance is a significant problem and a major challenge for every

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health care team. Noncompliance can result in reduced effectiveness or failure of recommended interventions with detrimental effects on the patient’s subsequent health, on the effective use of limited healthcare resources, and in evaluating the “real” clinical efficacy of healthcare interventions (Paddison, 2002). The term compliance generates controversy because of the implication that the healthcare provider is in control and dictates what patients should do. The way this term has been used has led to a tendency to blame the client; noncompliance is viewed as irrational and deviant behavior. This could account for the move away from this term in the literature, with adherence, patient cooperation, maintenance, and therapeutic alliance being used more frequently (Paddison, 2002). To many authors, compliance connotes an underlying authoritarian dictatorial tone on the part of the health care givers and an image of patients as yielding and acquiescent (Simons, 1992). The spectrum of definitions of compliance are seen to range from the extremes of the extent to which a person’s behavior coincides with medical or health advice to the more dignified definition of compliance being an active, intentional and responsible process of self-care (Kyngäs & Lahdenperä, 1999). This distinction introduces the concept of motivation as a special interest to healthcare professionals who are responsible for promotion of health behaviors and rehabilitation. Motivation is inextricably linked to behavior as it refers to a type of global dynamic structure responsible for action or to a specific tendency toward some specific actions (1999). Also, research studies have concluded that

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the best psychological determinant of exercise compliance and the performance of other health behaviors is motivation (Dishman & Ickes, 1981). Other social and psychological factors thought to influence compliance are identified as (a) knowledge and understanding including communication, (b) quality of the interaction including the patient-provider relationship and patient satisfaction, (c) social isolation and social support including the effect of the family, (d) health beliefs and attitudes-health belief model variables, and (e) factors associated with the illness and the treatment including the duration and the complexity of the treatment (Corvera-Tindel, Doering, Gomez, & Dracu, 2004). Surprisingly, there is also data that has shown that compliance is not however necessarily associated with clinical outcome (Friedrich, Gittler, Arendasy, & Friedrich, 2005; Sluijs, Kok, & Van der Zee, 1993). I found overlap in our PBS experience for each of these factors cited in the literature for noncompliance.

Reasons for Noncompliance Patients do not comply with treatment for a wide variety of reasons. Reasons for noncompliance include the requirement for difficult lifestyle changes, complex and extended periods of treatment, poor client/practitioner interactions, cultural and health beliefs, inconvenience, lack of time, motivation problems, and poor social support networks have been implicated (Paddison, 2002). Lewis, et al. (2005) found the main reasons given for failing to continue with the exercises for chronic back pain in their study was time management and laziness. While our

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group could point to most of those reasons as influencing their noncompliance, laziness was not an attribute I observed in any of the participants. Elsewhere data suggests that from one third to two thirds of patients are noncompliant with exercise especially regarding unsupervised exercising at home. Patients that are no longer motivated by their therapists and do not receive any feed back about their progress were also identified as reasons for non-compliance with exercise (Friedrich, et al., 2005). We certainly spent time with requests for more feedback and specific directions for home action cycles. Perceived ability and difficulty were related to intention to exercise as important considerations for back pain sufferers (Trafimow & Trafimow, 1998), though most of our activities were very simple movements. In cardiac rehabilitation an 87% noncompliance was typical of selected participants in a high-profile research project with the author wondering if there is any prospect that the patients who are seen in general practice or non-life threatening condition will adhere to an exercise prescription (Shephard, 2001). While we struggled with regular daily compliance, our experience was certainly much better than an 87% noncompliance, though no specific measurements were taken. The discussion now turns to reviewing what factors facilitate compliance.

Suggestions to Enhance Compliance There are a number of ways known to promote compliance with therapeutic regimens based on the assessment of the social and psychological factors involved in patient compliance (Cameron, 1996). Of primary importance is that an individual approach should be adopted (Cameron, 1996). This we 164

discovered with those who took advantage of the individual sessions offered during the PBS. Cameron (1996) stated that a therapeutic patient-provider relationship is also paramount, along with effective communication. Forming a therapeutic alliance should be developed and continuity of care should be maintained for good compliance (Cameron, 1996). The patients that are given information that is clear and unambiguous and have their understanding of how to perform the exercises assessed also maintain better compliance (Cameron, 1996). A sensitive empathetic approach by the practitioner is important and should try to understand the patientsâ&#x20AC;&#x2122; motives, demands and expectations as well as their health beliefs (Friedrich, et al., 2005). Supervision should be increased, for example with reminders or reinforcement and, if possible, the treatment regimen modified to reduce complexity, duration, costs and inconvenience (Cameron, 1996). Existing social support strategies of the patient should be identified and family members encouraged to give emotional and physical support and to be involved in the patientâ&#x20AC;&#x2122;s care (Cameron, 1996). Compliance to exercise for CBP is determined by several factors including that the exercises must be tailored to the type and stage of the disorder, the proper intensity, and performed with the correct technique (Friedrich, et al., 2005). Friedrich, et al. (2005) also found full benefits can only be achieved if the exercises are performed regularly and consistently, with patients attending all prescribed training sessions and maintaining the exercise regimen at home after active intervention has ended. Other authors recommend setting attainable goals in cooperation with the patient with a manageable number of instructions, spread

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out in a logical sequence which requires careful planning (Kerssens, et al., 1999). Both Kerssens, et al. and Åsenlöf, Denison, and Lindberg (2005) also recommend tailoring exercises and advice as much as possible to consider the patient’s particular situation and routines, integrating them into each patient’s daily activities. This an area that could be expanded and incorporated into future studies of the PBS now that the Åsenlöf, Denison, and Lindberg’s study is available for adaptation. Cognitive behavioral therapy for chronic pain offers specific factors that are successful in issuing homework (Johnson & Kazantzis, 2004). Three components of the homework rationale were found to be essential in the treatment of chronic pain. First an explanation that allows the patient to understand that their pain is not an immutable experience that is completely dependent on tissue damage (2004). Further, patients that consider CBT will cure their pain, expect medical interventions, or fail to recognize their own actions will be central to their rehabilitation, might require additional preparatory information or motivational enhancement (2004). The second component is an explanation of the assertion that cognitive and behavioral psychological interventions have the capacity to alter pain experience (Johnson & Kazantzis, 2004). Johnson and Kazantzis (2004) found patients will be more likely to complete homework if they understand its purpose, and how it will help them achieve their treatment goals. Patients required a clear description of how the tasks are matched with their presenting problems and will aid in the management of their condition. Pain sufferers that remain unconvinced

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might still benefit from such interventions if it is explained that these interventions are able to impact on the consequences of their chronic pain such as their stress level and their mood (2004). The third component is an assertion that home practice will be an important contributor to the success of treatment and the need to practice any new skills in order to become proficient (Johnson & Kazantzis, 2004). The assignments were also enhanced by the specificity of homework. Johnson and Kazantzis (2004) noted practitioners should regularly outline when, where, how often, and how long homework should take to be practiced. Assignment of homework should involve in-session practice of the task, augmented with therapist modeling where appropriate. Patients seemed to do best with very specific assignments (2004). Had these factors been adhered to in this study many of the complaints in this area would not have occurred. These suggestions do not however address how to have prepared handouts for an agenda that is open to change and modification by the will of the group, as was noted in Chapter IV.

Past Discussions of How to Address Motivation and Compliance While the literature has sought various measurable variables of compliance, the discussions always seemed to remain on a dry, superficial level of inquiry. In my opinion it was as though the search ended by asking the noncompliant or compliant participant to check the right box on the input form. Where were the individual, unique reflective answers to the reason behind the reason? In yoga this reason behind the reason is referred to as the causal body,

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that part of the human experience that gives meaning and purpose to one’s life, or as defined for this study, spirituality (Taylor, 2003). No studies were found where there was a discussion of spirituality or religious beliefs. There were some calls for understanding that motivation is dynamic and is influenced and affected by many interactive factors (Sabin, 2005), but what these factors are or how to address them was not provided. The inflexibility of the curriculum and the need for standardization has constrained both the investigators and the documentation of the spiritual factors. One study on patients with CBP required that quantifiable progress be made in exercise performance during each treatment, postulating that such a requirement guaranteed that improvements in physical performance would occur for all patients (Hartigan, Rainville, Sobel, & Hipona, 2000). Such an approach ignored the many interactive factors that can influence exercise performance in people with CBP, reducing participants to an impersonal object to be processed. Another study suggested positive feedback for successful completion of exercises and for progress made in treatment, to include a reward of a hot pack for working through pain were reported to also have had an effect on adherence to exercise (Fritz & George, 2002). Certainly addressing fear-avoidance has been documented to affect adherence, but it would seem a less Skinnerian approach such as the “playing the edge” component our PBS, which was based on the work of Butler and Moseley (2003). Another study had a mathematical equation where components in the numerator of the equation identify factors that affect motivation including perceived chance of success and perceived importance of the

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goal while the denominator was composed of perceived costs and the inclination to remain sedentary (Phillips, Schneider, & Mercer, 2004). Elsewhere in cooperation with the patient, the therapist developed reward and punishment strategies (e.g., saving up money for a special purpose), with particular attention placed on positive reinforcement (i.e., rewards for exercise compliance) (Friedrich, et al., 2005). In a cardiac study the reasons for difficulty following the diet included lack of motivation and self-control, but no inquiry behind those reported reasons for non-compliance (Evangelista, et al., 2003). They did question how to arouse the patients’ responsibility and desire to set goals for their own treatment, but concluded the most important aspects are to define and operationalize the phenomena adequately and to test the reliability and validity of measurements. Evangelista, et al.’s (2003) desire to find a valid and reliable measurement appears to be an example of not being able to see the problem may be in not asking “how” and “‘why” rather than asking the right question for quantification. These past discussions in their objective style of the quantitative method seem to depersonalize and inadvertently dehumanized the inquiry at hand around compliance. Participants are neither rats in a cage or numbers to be tweaked. While we as a group were not able to solve the problem of compliance, our inquiry pointed to the many broader systems influences as outlined in the results as additional factors. Most importantly, to include myself as a participant and researcher, the failure to comply asked much deeper, spiritual questions that

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remain for each of us to explore and investigate on our own as the process of selfcare continues. There are other areas of inquiry that have been mentioned in the literature that could enhance the future PBS curriculums. The discussion now looks at those areas as further suggestions for research in caring for people with CBP.

Areas of Inquiry to Broaden the View and See the Whole The literature review indicated that the transition from acute to chronic back pain is known to be influenced by physical and nonphysical factors, which are interwoven in a complex fashion. The more exhaustive the identification of all contributing physical and nonphysical factors the more enabled the treating provider should be to enact a comprehensive approach with the best chance for success (Wheeler, Stubbart, & Hicks, 2004). Humility is in order when approaching both care and research for chronic back pain, whether the care is in a group or in a one-on-one model. Given the state of evidence, prudence necessitates that physicians, chiropractors, and physical therapists very critically examine their current practice patterns (Carey & Freburger, 2005). The inquiries should not be limited to single interventions, but also to understanding the processes of treatment change in individual and group approaches. Adopting a process view would allow the approaches to studying CBP to evolve to include not only interventions, but the examination and evaluation rules that are used to select and progress such interventions (Delitto, 2005). The following is a list of

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suggestions for deeper and broader inquiries in the education and treatment of CBP. Psychological factors: Current intervention guidelines encourage early detection and appropriate management based on the premise that this may lead to better outcomes, minimize the financial cost to the individual and society, and prevent the recurrence of both depression and low back pain (Pincus, Burton, Vogel, & Field, 2002). Studies measuring the relationship of breathing, postures, somato-emotional awareness and mood may shed further light on bridging psychology and physical therapy. Our group found that type of work very helpful. Spinal loading and psychosocial stress: There is a psychosocialbiomechanical interaction that defines physical loading on the spine. One study had imposed moderate loads on the spine and found that small increases in spine loading occurred in response to psychosocial stress (Marras, Davis, Heaney, Maronitis, & Allread, 2000). The compressive loads increased by an average of 7%, with even larger increases seen for certain types of individuals (e.g., introverts [13.7%] and intuitors [10.8%] (Marras, et al., 2000). Further study of these relationships by personality types and spinal loading may help to further tailor interventions to the individual patient. Beliefs and pain: Helping persons with pain to recognize and change maladaptive beliefs and coping strategies and to increase the use of adaptive coping strategies improves pain and physical and psychosocial functioning (Turner, Jensen & Romano, 2000). Specific beliefs that have been shown to be associated with poorer adjustment to pain include the following: (a) that one

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cannot control pain, (b) that a medical cure exists for one’s pain, and, (c) that pain signifies physiologic damage and therefore physical activity and exercise should be avoided. In contrast, specific beliefs and behaviors associated with better adjustment include the belief that one has the ability to control one’s pain, and the use of relaxation techniques and physical activity (Turner, Jensen, & Romano, 2000). Our use of narrative reflection suggested an important tool for discovering these beliefs about pain. Studies that explore what types of reflections and tools for guiding narrative reviews are effective would be valuable research topics. Tailoring advice and exercises: There have been calls for exercises and advice to be tailored as much as possible in considering the patient’s particular situation and routines (Åsenlöf, Denison & Lindberg, 2005; Kerssens, et al., 1999). Adherence is even better when these instructions are also integrated into each patient’s daily activities (Åsenlöf, Denison & Lindberg, 2005; Kerssens, et al., 1999). Refinement of Åsenlöf, Denison, and Lindberg’s (2005) method of individualizing treatment utilizing a CBT approach is in order and could be made a part of a PBS. More investigation into self-care strategies for engaging patients in problem solving to overcome ongoing activity limitations, enhancing patient confidence in self-care, and addressing specific patient worries are important components in back care and such investigation would increase the understanding of the patient’s unique situation (Von Korff, et al., 1998). Integral approaches to care: Suggestions have been made for more holistic or integral approaches (tai chi, yoga, and other ancient healing arts) to rehabilitation beyond compartmentalized discipline care (Davis, 2000; Kaplan,

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Harrison, & Galantino, 2000; Taylor, 2003; Taylor & Majmundar, 2000). The translation of these practices into the terminology currently used in neurophysiology and cognitive behaviorism may reveal new insights into the ways that ancient practices are continuing across the centuries and improving CBP care. Social influences and behavior patterns: Studies on the acceptance of chronic pain revealed suffering occurs when behavior to avoid pain, enhanced by social responses, is also behavior directed away from such things as family, friends, health, and productive functioning. More study is called for to learn how to marshal social influences, including cultural, family, and therapeutic, in a direction that would support patients with CBP (McCracken, 2005). Anger and forgiveness: Suggestions for more study come from a preliminary study, which found there is a relationship between forgiveness and pain, anger, and psychological distress in patients with chronic low back pain (Carson, et al., 2005). Patients who report an inability to forgive others might be experiencing higher pain and psychological distress that are mediated by relatively higher levels of state anger (2005). These findings indicate that forgiveness can be reliably assessed in patients with persistent pain, and that a relationship appears to exist between forgiveness and important aspects of living with persistent pain (Carson, et al., 2005). Addressing this topic of anger and forgiveness in back schools would bring additional depth to future inquiries. Spiritual care: While the most appropriately trained professionals should provide care, the authors agree that all primary healthcare professionals have an

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important role to play in spiritual care (Handzo & Koenig, 2004). More studies beyond this PBS study are needed that would expand on the methods and tools for intervention and support of the spiritual aspects of CBP. The participants in this PBS found exploration of spiritual questions to be one of the most helpful areas of inquiry. Each of these mentioned topics could broaden both the providers’ and the patients’ understanding and knowledge about the CBP experience. While trying to build a curriculum that addressed all these would bring us back to the problems of predictability noted earlier for TBSs, the freedom for each new group in a future PBS is that they build the curriculum of expanded topics that suits their unique needs and diversity. The next section of the discussion introduces broader questions that remain to be explored based on this study.

Suggested Research Questions for Consideration This study has opened multiple fields of inquiry for those looking for fresh perspectives and topics in the present day context of supporting those with CBP. Introducing these topics into the literature will certainly raise more questions than it answers. Some of those questions are: •

How do the boundaries between disciplines limit or invite such a transdisciplinary approach?

•

How do academic institutions move out of the one-on-one treatment model and begin to teach group skills?

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•

Is the public ready for this depth of inquiry and willing to do the “work?”

•

What evidence will third-party payers and the public demand to pay for this service?

•

Can someone who does not participate in their own ongoing process of mindfulness/participatory inquiry teach this work?

These questions point to many research opportunities across disciplines. Many years of dialog, bold initiative, and creative programming will be needed to bring these questions to the mainstream of medical research. In the meantime here are three areas I would most like to see addressed in the near future: •

Replication of this study with slightly larger groups (10-12), incorporating elements of Åsenlöf, Denison, and Lindberg’s (2005) individualized tailoring into home action cycles, and additional measurements of change of function and quality of life.

•

The development and measurement of clinical tools for physical therapists to address emotions and spirituality in both group and individual care settings.

•

The use of this method for other common physical therapy diagnoses to include hemiplegia post-CVA, post-joint replacement, headaches, fibromyalgia and so forth.

Reflections on Self-care vs. Self-neglect: A Larger Systems Issue

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In our experience of PBS we learned that our pain could be used to deepen individual inquiry into who we are and how we want to act. Together we discovered that pain could be used to illuminate the gaps in who we said we were and how we acted. This tendency toward “self-neglect” over “self-care” wreaks personal suffering as we objectify our “bad backs,” forging ahead by shutting off our individual awareness and sensibility. Such neglect is a tragedy in and of itself. The bigger tragedy we discovered as we adopted a transdisciplinary perspective is that we are not isolated individuals with our suffering, but interconnected living systems who affect not only ourselves, but all of the systems of which we are a part. In return those same larger systems that drive and influence our individual behaviors desperately need to restore and acquire their own awareness and sensibility. In many ways the neglect of our caring for ourselves is a form of violence in effect. The violence we inflict on ourselves when we fail to remember our pain on many levels fuels the violence of the larger systems on our environment and between peoples. Our approach to inquiry about CBP must be inclusive of the valuable information obtained through the old approaches, but it must also honor the humaneness of true evidence-based practice. When we no longer have time or can not “afford” to connect with ourselves and our patients at a heart/spirit level, we have become badly lost in our search for healing.

Summary and Conclusion

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The Results section of this document identified a variety of benefits, skills, tools for participants as wee and the Discussion has pointed out both important findings and directions for future research. Because the co-researchers themselves stressed the importance of the following elements of the study as being especially important and transformative, they bear repeating. •

The several opportunities to discuss, from their own perspective, the experience of the pain they were suffering, what they perceived its source’s to be, and how they related to the pain—what it meant to and for them—were particularly helpful.

•

Their experiences in the PBS either heightened or reinforced their expectations of the kind of care they wanted to receive—i.e., to be treated as unique individuals in and to receive the best care available.

The discoveries we made as co-researchers in our PBS experience has emboldened me to explore the new horizons promised in a transdisciplinary approach. We can as providers and researchers rise above petty, antiquated turf arguments about discipline boundaries. We can also engage in constructive dialogues between disciplines to advance transdisciplinary understanding in the service of our patients and ourselves. These are strong assertions that will require courage (great heart) moving forward. Peter Senge offered us both encouragement and a challenge when he commented on the relationship between local and larger systems: “What is most

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systemic is most local” (Senge, Scharmer, Jaworski, & Flowers, 2004). That is, our personal practice has profound effects on our larger systems, therefore how we care for ourselves influences how others are cared for. In my review of the literature I discovered an amazing bit of evidence about we human beings that is no coincidence for a social, interconnected species. Van Houdenhovea & Luyten (2005) discussed the role of life stress on chronic pain and reported the findings of Eisenberger and Lieberman (2004) who were able to visualize through brain imaging that the same areas of the brain are active with chronic pain as with the emotional pain of social exclusion, leading Eisenberger and Lieberman to conclude that physical pain and the emotional burden of loss and of decreased self-esteem may overlap in their underlying neural circuitry and computational processes. So regardless of whether depression or social isolation causes CBP or vice versa, I find it fascinating that we appear to be “hard-wired” to be included and care for one another in humane and meaningful ways. I believe we are up to the challenge of caring for ourselves as we care for one another and will make it my life’s work to help us “re-member” our pain.

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APPENDICES

Appendix A: Intake Interview Questionnaire Intake Interview Questionnaire Dissertation Study Health History and Intake Interview

NAME: ________________________

DATE:___________

Please indicate if you have or have had any of the following: Condition

Yes

Asthma Arthritis Blood Problem High Blood Pressure Cancer Diabetes Heart/Lung Muscle, Joint, Bone Stomach Stroke/TIA Physical/Sexual Abuse

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Describe/When ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

SURGICAL HISTORY: (If yes, when and what type) Abdominal Bladder Uterine Prostate Bowel Orthopedic Spine Heart Lungs Plastic Other

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Please list current medications and allergies: __________________________________ __________________________________________________________________ ______ 191

Please indicate your pain level below: _____________________________________ 0 10 No Pain ER visit 1. How long have you had your spine pain?

2. Where is it located?

3. Do you know what is causing your pain?

4. What care have you received in the past?

5. What self care measures are you participating in regularly now?

6. Have you been to a back school or pain clinic before? If so, describe your

experience.

7. How has spine pain affected the quality of your life?

8. What do you miss most that the pain prohibits you from participating in?

9. Did you experience any disappointments in your care? If so, what were they?

10. Why did you agree to participate in this study?

11. What do you hope to gain or contribute through participation?

12. Have you done any group work around the challenge of your spine pain? If so, what was that experience like?

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13. What would you like to learn about in a back school?

14. Is there anything you definitely do not want to do or study in this program?

15. Does stress or other environmental conditions effect your back pain? If so,

how?

16. When interacting with prior care providers, did you note an absence of any particular skills or â&#x20AC;&#x153;bedside mannerâ&#x20AC;? that would have been more supportive in your healing process? Did you note any that were especially helpful?

17. Do you have anyone you regularly share your experience of spine with?

18. Are you aware of any skills or abilities that you lack or do not utilize that may have been or in the future may be useful in improving your experience of spine pain? If so, what are they?

19. During your experience with spine pain, have the emotional and spiritual effects of this pain been addressed or inquired about by any of your caregivers? If not, would you have liked to have had these issues addressed? If they were, what was your experience?

20. What else should I know about your experiences with spine pain?

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21. Any other questions before I describe the process of the back school?

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Appendix B: Dissertation Study Exit Interview Dissertation Study Exit Interview

NAME: ________________________

DATE:___________

Occupation: Age:

Please indicate your pain level below: _____________________________________ 0 10 No Pain ER visit 1. Do you view your spine pain history any differently than you did before class? 2. Have noticed any change in your pain and if so, how?

3. Do you NOW know what is causing your pain?

4. From what you learned here, will it influence the care you seek in the future? If so, how?

5. What self care measures have you added and are participating in regularly now? 6. What was your experience of the group, your role, any learning that came from the group?

7. What would have improved the class? (physical set-up, equipment, number of people, meeting time or place, etc)

8. How has the class affected the quality of your life?

9. Are you more or less optimistic about living with your chronic pain experience having gone through the class? 195

10. Did you experience any disappointments in the class? If so, what were they? 11. Would you recommend this type of experience to others with spine pain?

12. Did you achieve what you hoped to gain or contribute through participation? 13. What skills or abilities would have helped the facilitator better manage the course? 14. What skills or abilities helped the facilitator manage the course?

15. Was there anything you wouldn’t want repeated in this program?

16. Do you perceive stress or other environmental conditions differently in their effect on your back pain? If so, how? 17. When interacting with prior care providers, did you note an absence of any particular skills or “bedside manner” that would have been more supportive in your healing process? Did you note any that were especially helpful?

18. Did you experience any value in sharing your experience of spine pain or will you seek to do so in the future?

19. Are you aware of any skills or abilities that you lack or do not utilize that may have been or in the future may be useful in improving your experience of spine pain? If so, what are they?

20. Did you experience any physical, mental, emotional or spiritual effects of this pain that you need or want more help with in the future? 21. What else should I know about your experiences in the group?

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Appendix C: Participant’s Journal Weeks 1-7 Participant’s Journal Week 1-7 Coming to the class I felt….

During the class I felt ….

At the close of the class I feel…..

The class would have been better if… The group is….

Home action steps: 1. 2. 3. 4.

Home Reflections: (Date/Action/Observation-Reflection)

Over for more reflections/questions before next week…. 197

Appendix D: Participant’s Journal Week 8 Participant’s Journal Week 8 Coming to the class I felt….

During the class I felt ….

At the close of the class I feel…..

The class would have been better if… The group is….

Things Matt could have done differently to improve the experience are….

Home action steps: 1. 2. 3. 4.

198

Appendix E: Participant’s Journal)

Completed Narrative for the Active Back Support School

People come to Active Back Support school experiencing a reality which they would like to change or better “control.” People are “meaning-making organisms” that create stories (narratives) to make sense of what they perceive and experience in the process of living. Surprisingly, a fair number of people are unaware of what that story is, their role in the story, and the power that the story carries in generating what they experience as “reality.” 199

Discovering the Story The process of discovery, or “inquiry” into that story is what SPSI is all about. The inquiry in this method is actually a form of research (= coming to a new understanding of reality.) Consequently, we can actually describe all of those involved in SPSI as “researchers or investigators.” When a person begins to research the many personal systems that influence their story, like any investigator they will be more efficient and effective if they have guidelines or tools to assist the process. At DSR we identify those tools and assist the individual in discovering or acquiring those that are not presently available for their use. There is no cookbook or “one size fits all” tool bag for SPSI, however. Your care at DSR is designed to uniquely identify for you the skills and strategies that might best assist your inquiry. Rewriting the Story What are some of these tools or skills? While there are probably an infinite number based on personal histories and circumstances, it is helpful if we first step back and ask, “What is it we are trying to foster in this inquiry?” We at DSR believe the process of SPSI is a creative one, where working together we discover creative alternatives for interpreting and experiencing the “reality” of the complaint that brought you to DSR. Research has discovered the following 5 broad traits or categories that distinguish creative individuals and organizations.(Barron, F. (1990) No rootless flower. Towards an ecology of creativity. Cresskill, NJ: Hampton Press.) Within each of these traits lie opportunities to discover and develop your unique tools for generating a unique and creative strategy for you: 1. 2. 3. 4. 5.

Independence of Judgment Tolerance for Ambiguity From Polarizations and Oppositions Thinking to Complex Thinking Androgyny (clarity on gender attributes and roles) Complexity of Outlook, Symmetry/Asymmetry

The beauty of this science is that it is based on simple, effective practices. No expensive machinery, gadgets or equipment. The Challenge of SPSI The “hard” part of this science is creating the discipline to regularly do the work of inquiry. SPSI requires a commitment of time and action on the individual’s part. Practicing the simple movements and awareness exercises is not difficult…creating the time and following through with the straightforward periods of reflection and contemplation seems to be the greatest barrier. Everyone 200

at DSR is engaged in the same ongoing work of their own personal inquiry, so we understand and can offer reinforcement as you begin your discovery process of the Science of Personal Systems Inquiry!

Beginning Your Inquiry

The First Step We introduced the concept in the introduction that as humans, we are “meaningmaking” organisms. That is, we are living systems of cells and relationships that want very much to make sense out of our individual experiences. Pain, disease or injury can be experiences that suddenly do not fit in our old meaning of who we are as a human. Before heading off into your inquiry of making order of your present health challenge, it is important to spend a little time clarifying your present “story” of meaning. A Common Story in Our Culture We never make our stories of meaning in isolation. Our family, our history, our ethnic background and the culture we live are just a few of the “co-writers” of our story. Spending a few minutes on the shared story of health in our culture will be an excellent preparation for identifying your unique version of that story. For the past 400 years Western medicine has been developing a story of health that is told to us every day on the news, in ads and by many in the healthcare system. Roughly speaking, that story runs along the lines that the body is a machine and when it isn’t working properly, the key to restoring health is identifying the part or parts that aren’t working. Those “parts” then are either adjusted (medication or surgery), replaced or removed. Buy the right pill, get the right treatment after the right test, and you are back on the road to good health…very much like bringing your car into the shop for repairs, isn’t it? For many conditions, this story works well. Unfortunately, the decline in health and increase in chronic disease in our country suggests that there is more to the story. A human being appears to be far more complex and individual than the usual model in the auto repair story of modern medicine: Spirit/Soul Mind Your mission in beginning SPSI is discover what parts of that story are yours, what needs to be updated or changed, and then be able to “make sense” of the Body 201

present health challenge you are experiencing. What you will discover is that your ability to move and be comfortable in your world is related to much more than any single part or parts. Only in discovering those relationships will you have the ability to learn new skills and strategies to effectively create the healthiest future possible for yourself.

Your Current Story Too often we are tempted to skip the most important step: clearly describing our present story of our health. “Oh I know my story, just give me a new story” is a common response. Not too much of a surprise, as such an attitude reveals the degree to which we have fallen into the dominant “mechanical” story of our culture…. “I have a broken story, just give me a new one and I’ll be better.” What we have learned at DSR is that investing some time early on in your SPSI is critical as a researcher for discovering how to best help yourself heal. Review the following questions briefly, then schedule a block of time in the next day or two to write out your answers in good detail. The physical act of writing the answers is much more powerful than just thinking the answers. Remember, you are worth the time to do this research right! 1. How do you see your present health challenge(s)? As unavoidable, a punishment, unfair, a teacher or lesson, an opportunity, a nuisance, a challenge to overcome…? What story do you tell yourself or believe about the origin and purpose of these challenges? You probably have several stories…there isn’t necessarily a single story, so reflect on all of those that apply to you.

202

4. Are there any environmental factors or influences in your story that affect your health (weather, the news, economic changes, your insurance company, etc.)? Can you jot a few examples?

5. In your story, what, if any role do your emotions, thinking and spirituality have in living with this condition? If none, state that as well.

You did it…well done! Now you know where you are starting your SPSI. There are no right answers to any of the questions above, so do not worry about a grade or getting it “right.” Chances are your story is going to change anyway. Another Story for the 21st Century Presently there exists another story of health that is both old and new. This “new” story is quite different from the simplistic, parts-oriented mechanical story that we have just discussed. Rather than parts, the story looks at relationships, or systems (hence the name DSR) and is a much “messier” story than the car analogy. Elements of this story have been around over 4300 years and are also emerging as the latest news in modern medicine. Here is the ancient version in a nutshell followed by a picture for comparison. This story is not the last or final story, but as you will come to discover, the story holds out much promise for new options for supporting your present health challenge. 203

The sum total of a healthy human is product of many interrelated systems within the individual AND their larger environment. Each of these systems has both direct and indirect effects on the health of the individual by their many complex and interwoven relationships. There are no neat compartments of “parts” such as the body, mind or spirit…each is intimately woven together with the other, impossible to separate or pull apart. Consequently, your ability to move with efficiency and effectiveness depends not just on the physical parts (muscles, bones, joints, etc and the nervous system), but also on you level of stress, family and work environment, spiritual development, thought patterns and so forth.

Body Emotions Spirit Creativity

Thinking

The shaded area represents the whole of your experience…where all of the systems share a common connection and consequently affect one another. For example a painful low back sours your emotions, clouds your thinking, limits your creativity and dampens your spirits. Or, a broken spirit voids your creativity, generates destructive thoughts and grief or anger, slumping your posture creating strain on a vulnerable disc…nothing in our experience happens in isolation when we begin to examine these relationships between systems. All of those effects then color our work, our social relations, and so on, one continuous weave of connection. During your process of SPSI you will work together with the staff at DSR to develop new insights and strategies take advantage of these interconnections. You will discover and experience the effect that your thoughts have on your movements. You will experience the effect that body positions and postures have on your mood. You will begin to notice the traits that stymie your creative choices in health, and work to establish skills that transform those habits. When we encounter an area that requires expertise beyond our skills, we will assist you in locating additional expertise in that area, just as we would when we suspected an orthopedic condition requiring a surgeon’s attention. We do not pretend to be experts in all aspects of the human condition, but also we will not pretend those other areas have no effect on your movement potential. 204

Your Unfolding New Story Your story is just like you…always changing, never the same and in need of constant attention. The exercises and reflections of your unique SPSI will be an ongoing process tailored specifically to your findings in your personal research. The remainder of the book will be supplemented with “homework” based on what you and your DSR professional determine to be beneficial for you. No cookbooks or one-size-fits-all. The research method you will use is a simple cycle of two components: 1.) Action or activities to experience; and, 2.) Followed by reflection where you pause to pay attention to the effect of the action, your response to the action, and then intentions toward either repeating or modifying that action. The cycle begins again with the next round of action. We are all pretty good about doing, then doing some more or quitting. The slowing down and recording your response is the difficult part. We will work with you to discover the enjoyment and the sense of creativity that applying the periods of reflection introduces to your life. The beauty of this approach of inquiring into the systems effects is that we do not just teach you what to do, but rather how to determine what to do as a life skill that will continue to serve you long after you are finished at DSR.

Your process of SPSI is really just a research approach of: • asking new questions, • noticing ineffective and effective habits, • trying new doing, • and then asking more questions.

So let’s begin with your first cycle of research….

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Appendix F: Consent Form

Consent Form Matthew Taylor, a doctoral candidate at the California Institute of Integral Studies in San Francisco, is conducting a study regarding the experiences of participants in a participatory back school titled, Active Back Support. Participation involves: attending a private one-hour intake and orientation; attending eight weekly two-hour classes; participating and reflecting on agreed activities between classes; recording reflections and experience during the eight weeks; sharing what you choose to share of this journal with Matthew Taylor; sharing what you choose to share with the other participants in the inquiry during class; and participating in a final private one-hour exit interview. All interviews and class sessions will be recorded via audiotape. There also may be video recordings and pictures taken during the classes. In all of these activities, your participation is completely voluntary and, at all times during the study, you have the right to not answer any question and to raise any question that you choose. All audio and video recordings, and any pictures taken during the study, will be stored securely in Matthew Taylor’s possession. All contributions will be given pseudonyms, and a list of names linked with pseudonyms will be locked in a location separate from the data; if anyone were to come upon this study’s data, participants’ names would not be available with this data. At this time, there is no intended use for this material other than transcribing the audio portions for written analysis of data. If at any time in the future, Matthew Taylor wishes to use a portion of your recorded material or a picture that includes you, he will first obtain your written permission for each usage that he intends. All data will be destroyed after five years. Any presentation of written material from this study will completely protect the identity of the author of the material. Findings will be presented in general form and, where specific citations are used, they will be chosen with the aim of protecting confidentiality. In a doctoral study, there can be no guarantee of direct benefit, and no guarantee is offered. That said, you will engage in a practice designed to support individuals with chronic back pain and – as someone experienced with chronic back pain – you are familiar with the benefits of some activities, and you also know that there are risks involved even in the gentlest of activities, which will be the only activities undertaken in this study. The risks should be minimal and no greater than those encountered in daily life. You can expect the possibility of experiencing deep feelings during the process, including perhaps unpleasant ones, and you can also expect awarenesses, insights, and thought-provoking experiences that may provide significant benefit for you during and after the study. In addition, there is the possibility that your participation may create significant benefit for others who read about and participate themselves in future experiences such as this one. 206

Matthew Taylor will be available before, during, or after the study to talk about your concerns, and to facilitate referrals to physicians, consultants, or therapists if such a need should arise. Matthew Taylor will assist you in finding appropriate support in your area if needed. Matthew Taylor can be contacted at (480) 201-5692. You may withdraw from the study at any time for any reason. In addition, if you have concerns or are dissatisfied at any time with any part of this study, you may report your concerns â&#x20AC;&#x201C; anonymously if you wish â&#x20AC;&#x201C; to the Chair of the Human Research Review Committee, California Institute of Integral Studies, 1453 Mission St., San Francisco, CA, 94103, or by telephone at 415-575-6100. By signing below, you give your consent to participate in this study.

I, ___________________________, consent to participate in the study of the Active Back Support back school conducted by Matthew Taylor of the California Institute of Integral Studies. I have received a copy of this consent form, and I understand that my confidentiality will be protected within the limits of the law.

______________________________________________________ Signature Date

If you would like to receive a written summary of the results of the study, please provide an address where it can be sent to you: _________________________________________________________ Street City Zip

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Appendix G: Opening Night Checklist Opening Night Checklist

Confidentiality Forms: Questionaires Consent forms: Complete first question: Coming to class I felt….. Comfort…sitting, during activities, pillows/blanket

What it is: CI Research….hopefully to introduce a new method….descriptive, so your uncensored input is very valuable…can’t “flunk” me, so be honest! Principles of CI: Democratic, empowering, 4 ways of knowing, emotional maturity, fluid, cycles of action/reflection Does involve looking at assumptions/paradigms and that can be upsetting…so keep me posted and call anytime for support. What this isn’t… passive, repetitive, get through it attitude, “ask to change or report discomfort” Decision of data collected, uses and presentation Brainstorm agenda: My ideas: Breath work Sound/voice for healing Playing the edge Range of Emotions Mindbody science made practical The head-tail connection SPSI Transformative Movement Education Initial presentation: New story …what are we Value of reflection not carried in our culture…non-doing TME cycle and four ways of knowing…. Let’s experience…. 208

Homeworkâ&#x20AC;Ś. Complete now the next four questions SPSI assignment Questions?/Comments?

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Appendix H: Completed Narrative Completed Narrative This is an example of a completed narrative. For the full context of this questionnaire, please see Appendix E. Participant’s Journal, The Science of Personal Systems Inquiry (SPSI).

…What we have learned at DSR is that investing some time early on in your SPSI is critical as a researcher for discovering how to best help yourself heal. Review the following questions briefly, then schedule a block of time in the next day or two to write out your answers in good detail. The physical act of writing the answers is much more powerful than just thinking the answers. Remember, you are worth the time to do this research right! 1. How do you see your present health challenge(s)? As unavoidable, a punishment, unfair, a teacher or lesson, an opportunity, a nuisance, a challenge to overcome…? What story do you tell yourself or believe about the origin and purpose of these challenges? You probably have several stories…there isn’t necessarily a single story, so reflect on all of those that apply to you. Hurt my back as a teenager moving a piano. Re-injured as adult moving TV’s. Added weight has created recurring episodes often.

2. What is “causing” your challenge? What stories have you been told ( ie, a bad disc, arthritis, some disease, etc)? Which ones do you believe? Which ones do you doubt? Do you have a story for a single cause? Cartilage between the last two vertebrae is getting compressed. Spine is losing natural curve.

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3. Does your story identify any characters or factors outside of you that influence your challenges (spouses, family, friends, co-workers, neighbors, etc)? If so, can you write down an example or two? In my work I sometimes am faced with the situation of having to move or carry something I shouldn’t. I love playing music but know by moving my drums it will most likely cause me problems. 4. Are there any environmental factors or influences in your story that affect your health (weather, the news, economic changes, your insurance company, etc.)? Can you jot a few examples?

Pressure from work, tension.

5. In your story, what, if any role do your emotions, thinking and spirituality have in living with this condition? If none, state that as well. Sometimes I think this is payback for not being the person I can be.

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Appendix I: Week 2 Week 2 Body Mind Spirit

Structure Organization/Relationship Process: Breath, attention, intention

Coming to Our Senses, Kabat-Zinn, J, Hyperion, NY, NY, 2005 Attention, connection, order, regulation, dynamic balance Breathing: note weight bearing, either sitting or standing pre and post: Diaphragmatic • As you inhale (I), belly softens and expands as diaphragm contracts. • You exhale(E), belly contracts and flattens. • Extend the (E) gently. 3 Part Yogic • 1st part: Diaphragmatic • Continue (1st part) filling solar plexus region (2nd part) • 3rd part: allow chest and ribcage to expand fully • Exhale in reverse order. Thermometer Breath: visualize thermometer…bulb in pelvis resting on pelvic floor. • In breath, watch mercury rise up front of spine to back of the throat…try not to skip areas on the way up. • Exhale, breath spills over the top of the spine and run down the back. • Watch for kinks, folds of blocks of the breath any direction. • This is an attention activity…so you “win” when you notice you stopped paying attention and come back to the activity to resume. Seat Adjustment: note wt bearing symmetry/asymmetry before and after. • Imagine each buttock filled with sand. Gently begin to pour or shift sand into one hip on an in breath. • Pour back into the other hip on the exhale. Repeat, slowly and evenly as possible. • Note where you are bracing/clenching as you move…soften there. • Also note where you are initiating the move (feet, hip, back, shoulders?)…see if you can start the movement using other parts of the body and discover which is less effortful. • Note sitting or standing weight bearing afterwards. 212

Crescent moon: • Begin by checking dimension and form around chest and underarms, foot pressure and height of each shoulder from the heel. • Keep weight equal on both feet. • You can keep inside arm on the waist if its easier. • Breathe arm up (we kept other arm at the waist) and keep feet pressing into the floor, fill the whole outer side of the body with breath. 10-15 breathes, then exhale down. Feel the difference, repeat to the other side.

Single Knee to chest: note leg length and space behind legs pre and post • Gently bring on knee up. On inhale feel lower belly and hips expand, on exhale, bring knee toward chest and you extend the leg on the floor. • As inhale returns, feel stomach expand and straighten arms. Repeat 1012 breaths. Then slow lower AND lengthen leg down along the other. • Note changes, repeat to the opposite side.

Hamstrings/Supta Padangustasana check leg length and space behind • Strap/belt/neck tie around ball of one foot and down leg straight if comfortable, otherwise can keep it bent. • maintain neutral spine, raise active down leg, press base of great toe and heel long, allowing outer thigh to turn in slightly and down, towards foot. Breathe. • Go only to first light resistance…not a hard stretch…breathe deeply and soften belly, hip, thigh, etc. May raise slightly after every 3 or 4 breaths. Play the edge, but only as far as full easy breath is maintained. • Release entire leg on exhale; lower and lengthen noting when your heel should hit the floor and when it actually does. • Check legs, check pace of thoughts. Repeat other side. Chest opener with strap: Note space across front and back of shoulders, and position of arms relative to the center (heart) of chest pre and post. • Holding a belt, towel, tie etc behind your back, soften knees and low back. • Begin 3 part breath and as chest opens, lightly pull on belt and feel chest open and shoulder blades come together. Repeat 12-15 breaths, watching for an additional opening and bringing arms/elbows closer, but not by arching low back or snapping knees back. • Gently release on out breath and note changes (check your feet and thinking too!)

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Please record reflections, insights, frustrations, etc in your workbooks. How does any of this change your story about your spine pain, if at all?????

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Appendix J: Week 3 Week 3 Emotions/Stress: Back Pain What are they and do we have any control of them? Mostly not aware by conditioning, thus not being able to change. Suggested book: Molecules of Emotion by Candace Pert Movie: What the #$%* Do We Know Activities: Emotional Awareness 1. Check in on each of a variety…we experience more than one at once. (joy, fear, anxiety, happiness, anger, peace, frustration, pessimism, despair, humor, boredom, curiosity, love, rejection, acceptance, loneliness, peace, cowardice, enthusiasm, numb, etc) 2. As you do, pause to see where you embody that emotion. 3. “Sit” with the strongest emotion and watch it as you breathe. 4. Come back after 3-4 minutes and check list again. Range of E-motions Exercise….feeling our feelings in our postures. Stress Awareness 1. 0-100 on tension scale…rotate through body parts assigning a specific exact number. 2. After completing, “look down” on your personal weather map of tension patterns. 3. Perform other practice. 4. Review map at completion and “sit” with the strongest area of tension 3-4 minutes. Come back to either or both of these when you experience spine pain and “notice”. Foot exercise: Stressed toes? Pain: Strength, coordination and stamina What is it you want to accomplish? Where do you feel “Strength, coordination and stamina” and where don’t you? Why? Can you modify it with breathing, movement and exercise…or do you need to rest? Exercise: Focus on the area and stay with it up to five minutes, watching carefully. Write down every characteristic about what you observed, like a 215

detective collecting evidence and a writer writing a creative story. Jot all of that down. Then spend another 2 minutes and record what changed. Is your pain always the same?

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Appendix K: Week 4

Week 4 Activities: Pain: Strength, coordination and stamina What is it you want to accomplish? Where do you feel “Strength, coordination and stamina” and where don’t you? Why? Can you modify it with breathing, movement and exercise…or do you need to rest? Exercise: Focus on the area and stay with it up to five minutes, watching carefully. Write down every characteristic about what you observed, like a detective collecting evidence and a writer writing a creative story. Jot all of that down. Then spend another 2 minutes and record what changed. Is your pain always the same? Strategies for sit/stand/sneeze Involves our ‘relationship’ with our support (the ground/Earth). Our attitude, both metaphoric and literal is the key. Remembering the breath is the pulse of the mind, we can begin by checking our thermometer breath…where are there kinks, wrinkles, or breaks…and more importantly what are the filters or stories we’re telling ourselves that create those? Structural/ergonomic considerations: Seat pan, feet, wedge support, spine support, visual alignment; match task to body (twisting/phone cradle etc) Exercise: Collapsed / On Guard-Anticipatory / The Middle Way…for sit and stand. Can you get to and feel all three, noting contact points, position of pelvis/spine and breath. What emotion/attitude does each carry as well….and not than any are correct, but why might that be “attitude” remembering that posture is the mirror of the soul. Pair up! Sneeze/Cough Protection: Open spine and support multidirectionally (feet, sitbones, hands both back and upper body). Other ideas/experiences?

Handling Materials: a relationship with others…note control of spine orientation but doesn’t have to be “frozen”…just awake and watch breath. Consider mechanics and moving through large joints (ankles, knees and hip joints) Exercise: Chair Dance with awareness

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Head to tail We’re really just a hollow tube with seals on either end…both of which are intimately connected where in one follows/leads the other. More importantly, they are regulated by our emotions/stress and spirituality…hard wired, not at a conscious level. Because of that we need to develop our inner awareness from last week and also explore what’s deeper than that (spiritual?). Look at our language around these areas: cat has your tongue, bite your tongue, hold your tongue, tongue lashing, choked up, hard to swallow, tight ass, anal, anal-eyes, verbal diarrhea, tail tucked, don’t have the _ _ _ _ _ to do it, …others? We often have chronic low level patterns of holding that we aren’t aware of …these generate tension and compression in the spine. Esp important is the tension generated by not speaking authentically or at all, to include fears, anger, needs and life issues. How many with jaw/TMJ last week? Exercise: Check Baseline Supine Thumb to finger tip, on inhale pinch while pursing lips and tucking in tail; soften all three on exhale. Differentiate top and bottom triangles: Lying on your back, knees up; Bottom triangle: think tuck tail; Top Triangle think close muscular tube extending inward. Then open/let go with forward pelvic tilt, neck curve down and ribs up vs. pelvic tilt back, neck curve up and ribs down. Eventually add finger tip/lips. Recheck Baseline Baseline Standing MiniTrampoline drills:…pelvic floor…diaphragm ….soft palate Standing: Lift pelvic trampoline…watch for changes with I/E…can you sustain lift through both? …what’s your tongue/throat been doing? Sitting: Watch for movement in pelvic floor on breathing deeply. Then sit forward, wide based, hands on knees, sense sit bones, …from center of abdomen watch pelvic floor trampoline from above…divide into four quadrants….drop glass ball on inhale, and on exhale pull up with threads to create uplift….go around to each quadrant and practice…then all 4 up on I….then all 4 down on E. Change vantage point to above diaphragm…same drill with diaphragm, esp back quadrants Soft Palate: explore palate with tongue and remember. Then cluck to feel trampoline of palate. Push tongue up then down and watch trampoline and cervical movement/tension. Then stretch tongue in all directions and recheck motion of tongue around mouth and palate. Then try lifting palate, noting cervical effort or movement. Yawn and feel movement of palate. Watch all 3 tramps with I/E moving up and down.

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Recheck baseline in standing, note changes….yield all 3 on I, gather up all 3 on E. Note posture, mind, and awareness. Check your trampolines often through the week…esp under stress or pressure or intense emotional situations…and can you respond differently now?????

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Appendix L: Week 5 Week 5 Activities: Review of Previous Actions and Plan for second half…

Pain: Strength, coordination and stamina What is it you want to accomplish? Where do you feel “Strength, coordination and stamina” and where don’t you? Why? Can you modify it with breathing, movement and exercise…or do you need to rest? Exercise: Focus on the area and stay with it up to five minutes, watching carefully. Write down every characteristic about what you observed, like a detective collecting evidence and a writer writing a creative story. Jot all of that down. Then spend another 2 minutes and record what changed. Is your pain always the same? Handling Materials: a relationship with others…note control of spine orientation but doesn’t have to be “frozen”…just awake and watch breath. Consider mechanics and moving through large joints (ankles, knees and hip joints) Exercise: Chair Dance with awareness

Exercise concepts/modification/nutrition Movement for learning vs “fitness”…mindful vs mindless…non-violent/nurturing vs violent/depleting Review playing the edge… Modifying traditional exercise: baseline: breathe/attend: recheck baseline Walking meditation…note “parts”, thoughts, breathing, mantra Nutrition: Comments of the western mechanical models and class input on experiences; The Healing Secrets of Food: A Practical Guide for Nourishing Body, Mind, and Soul and Feeding the Body Nourishing the Soul: Essentials of Eating for Physical, Emotional, and Spiritual Well-Being by Deborah Kestern… Sleeping/rest: a.m mobility/ beds/chairs and car seats/inversion tables? Look for online for homework Feb 15 or sooner and return to Matt by Fri Feb. 18th. 220

Appendix M: Week 6 Week 6 Online learning Activities… a little bit of history in the making: Hopefully you’ve played with the materials handling info during the week and noted how it worked or didn’t work for you…please make some notes in your journal. We also discussed at length at adding depth to your response when you do experience pain: supporting the area with breath, noting other patterns of tension/holding, screening for emotional response or awareness and just ‘being’ with whatever it is you find…the less is more concept of awareness and attention-- process changing structure and organization as we witnessed with DA Monday night. Now for this week: Abs: Back care (Pilates, yoga, sit-ups) Typically when we think of back care we focus on the painful back muscles and the abdominal muscles in front (I call them the front-back muscles since the spine actually lies in between them both). As a group we’ve already addressed three additional sets of muscles that are almost universally ignored in any article or treatment of chronic spine pain: the trampolines of the pelvic floor, diaphragm and tongue/soft palate. My experience is that when people increase awareness around those the front and back seem to “take care of themselves”…put succinctly folks that are either all wound up in the throat and pelvis with shallow breathing can do all they want to the front and back and their pain just laughs, while those who attend and develop awareness from their response in these areas experience increased levels of awareness and some control of symptoms. Having said that, what about the American passion for the six-pack abs…not to be confused with a Budweiser tumor!!! ; ) Well, tone and control/awareness of our core is important, but knowing how and when to invoke that tone is far more important and probably better for you than the misguided flat, V-shape figure (not unlike the same misdirected fashion we discovered with our feet and how ill-fitting most shoes are too.) A round firm belly that can be called in to stabilize is healthier than a hard, flat one that can’t let go…so let go of that image…it’s a story that first is probably not attainable and more importantly wouldn’t serve you anyway. We are better served by the T-shirt saying: “I have the body of a god…Bhudda”! Here’s a homework assignment: next Sat or Sun a.m. watch an infomercial on ab toning and really watch the direction and distance their spines move against resistance…and then ask yourself, do I ever move that far in that orientation (laying down, hanging over, seated, etc) in my daily life? The short is answer 221

“No”. But watch and see how artificial that activity is…we don’t ever do it in daily life! That violates a basic exercise principle known as “specificity of training”…if you want to get better at something, practice that activity…not some odd variant generated with 3 easy payments. Here’s your other activity besides critically evaluating the next ab ad you watch: It feeds off our materials handling exercise…find a box, bag or waste can with about 15-20 pounds of weight. Use that object to replicate what for you is a regular lifting task (groceries, children, yardwork, softener salt, etc). Simulate that activity with varying degrees of awareness to include simulating the movement breathing/not breathing/holding your breath. Then firming your various trampolines, softening them or splinting them. All the while noting your experience: ease or dis-ease…which feels more in control and comfortable, which fragile or uncomfortable? Then mix them up, going slowly to “watch” what happens…its your body…only you can evaluate what works for you….also notice if you press your feet evenly, arch your neck or soften it, thrust your tongue, etc…wake up to what you are doing and actively “experiment”…this research on you and you are one of the researchers. Dedicate to 10 min experiment sessions between now and the 21st and make some notes on your experience. Exercise # 2: Practice the Bastrika breath we learned last week…sitting or standing, do 10 rounds of 10 breaths where on exhale you forcefully draw up pelvic floor and abs, breathing out your nose as though you were trying to shoo a fly off the end of your nose…the inhalation is passive, followed by the forceful exhalation X 10….then rest 20 seconds, noting any changes in all the levels (physical, energetic, emotional, thinking and spirit)…repeat 9 more. If at any point you feel strain or light headedness, sit or lie down and rest. Resume when clear and slow down your rate. Do this 4 days in a row and note the tone around your bellybutton.

Breathwork/sounding: In addition to Bastrika…practicing your trampoline exercise, your 3 part yoga breath and regularly sustain a pelvic floor lift for 10-12 breaths are all great safe tools for gaining control and awareness. Another great exercise is called the straw exercise: find a soda straw, sit comfortably, arms relaxed, straw gently pursed in your lips but jaw soft. Check your baseline re: posture, thinking rate and content, etc. Close your eyes, relax between your eyebrows. For 5 minutes breathe through the straw, internally watching and listening to your breath as it moves up and down the straw, staying comfortable and resist changing your breath or making it right…that judgment thing! After you are done, journal on how that felt, what your mind did during the exercise and if you noted any changes on any levels. This is an attention exercise

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and as we’ve learned, attention and awareness are skills that require practice but with time our skill level increases as well. Finger Breathing: tent your fingers on your lap: thumb tip to thumb tip, index tip to index tip, etc for all five…I think you all have five! Close your eyes, soften your face, and with each breath you are going push lightly together one set of digits for the inhale, then relax that pressure on the exhale, next breath move up a digit. We’ll begin with the pinkies, then ring, etc up to the thumbs…at the thumbs repeat twice, then head back down. Do three full sets, noting if you can sense that the breath moves differently and fills a slightly different area depending on which fingers are pressing…don’t try too hard and then note how you feel afterwards in your journal. This a great one to do with your hands below the table at boring meeting, meals and lectures! (to include back schools!!!). Sounding: Vocalization or not vocalizing can modify our overall tone significantly…we are so good at “biting our tongue” in this culture. Play with this and see if you can sense the vibration (movement/exercise) each of the sounds creates in your body. Some may be easy to feel, others blank or flat…those are the areas for progress and uniting/yoking and healing. The sounds don’t have a literal translation, but are known to resonate with various levels of the spine…where you experience them? Repeat each 5-6 times, out load and exaggerating the “mmm..” at the end. Lum Vum Rum Yum Hum Aam Om Walking meditation…We walk everywhere but are almost always asleep to the experience of walking. This simple technique is just to wake up to our senses as we walk. I suggest using regular activities to practice: walking into the garage to the car and back, from the car to work, from the bed to the bathroom, etc. Note “parts” that participate and don’t, which foot falls heavier, which arm swings more or less, do you breathe and how? You’ll be surprise how much you change day to day and how much you can learn from your walk about the level of ease or dis-ease you are experiencing each day. Also note your habit of mind, watching which thoughts dominate during those routine activities…do they increase or decrease ease? Do you want to choose sensing vs. the wasteful rehearsing/remembering? What would be a little more nourishing and less violent right now? Are you worth it? People also find feeling the rhythm of breathing while walking can be peaceful as well…do you have your tail lifted in anticipation or are you walking at ease with steady confidence? Practice and see what “data” you discover about your habits while walking….do you think modifying some of that data would be healthy? 223

Yoga: see the attached chapter of an upcoming book chapter I was asked to contribute…it’s a handy, short reference piece in an easy Q & A format that I think will take you a long way in better understanding how yoga can support your health and back. Essentially everything we’ve done to date is yogic by the way. Pilates: head to my old business (you can tour if you want to learn more about this guy with crazy ideas like patients should get to ask questions and direct care!) http://www.taylorpt.com/pilates.htm . Bottomline: its advanced movement and do your due diligence shopping for an instructor who has a high level of training. And, despite what old German Joe thought, its OK to let go of your core tone much of the time during life! Cancelled until next meeting…this is getting to be too much! : )Sleeping/rest: a.m mobility/ beds/chairs and car seats/inversion tables?

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Appendix N: Week 7 Week 7 Activities: Sleeping/rest: a.m mobility/ beds/chairs and car seats/inversion tables? Discussed briefly the importance of maintaining neutral and varied support, and how to use breathing first thing in a.m. to facilitate mobility. Little good evidence around inversion tables and discussed principles and asked what caused the tension/compression in the first place requiring the inversion?

Review last week’s: Abs: Back care (pilates, yoga, sit-ups) Breathwork/sounding Bastrika

Practiced:

Reviewed:

Walking meditation…note “parts”, thoughts, breathing, mantra

playing the edge…

Spirituality Discussed how frequently what we profess (our creed or story about who we are, what we are and how we are to act) is in direct opposition to the way in our culture we maintain harried, over-committed lifestyles (to include volunteering for Back Schools!). Discussed how again our “stories” filter the stimulation we receive which then sets system wide tone, to include heart rate, blood pressure, muscle tension, pain perception, balance, etc. Automatic behaviors Regular, small amounts of practice lead to gradual shifts in patterns and habits, which produces automaticity.

Nutrition: Comments of the western mechanical models and class input on experiences; No further discussion.

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